ANNEX B

 

BEHAVIORAL HEALTHCARE SYSTEM ASSESSMENT 

Operation Iraqi Freedom (OIF) 

Mental Health Advisory Team (MHAT) 

 

 

16 December 2003 

Chartered by: 

U.S. Army Surgeon General 

This is an annex to the OIF MHAT Report addressing the Behavioral Healthcare 

System in OIF, including Kuwait and Iraq. The findings were obtained via direct 

observation, interviews and surveys, and data calls. 

This report is redacted to remove unit identifications, unit locations, and personal 

identity information in accordance with Army Regulation 25-55, Department of the Army

Freedom of Information Act Program, and Army Regulation 340-21, The Army Privacy 

Program. Redacted information appears throughout this report blacked out, such as 

below. 

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TABLE OF CONTENTS

ANNEX B: Behavioral Healthcare System Assessment............................................B-1

Introduction...............................................................................................................B-3

Findings ....................................................................................................................B-3

Recommendations....................................................................................................B-5

Presentation Of Data That Supports The Findings .................................................B-14

APPENDIX 1: Summary Of Behavioral Health Survey ..........................................B-19

APPENDIX 2: Summary Of Primary Care Survey .................................................B-27

APPENDIX 3: Summary Of Unit Ministry Team (UMT) Survey .............................B-32

APPENDIX 4: Summary Of Behavioral Health Interviews .....................................B-37

APPENDIX 5: Summary Of Line Leaders Interviews.............................................B-49

APPENDIX 6: Summary Of Behavioral Health Unit Data Calls .............................B-52

APPENDIX 7: Summary Of Fort Stewart Data ......................................................B-55

APPENDIX 8: Distribution Of BH Services ............................................................B-58

APPENDIX 9: Psychotropic Medication Issues .....................................................B-65

APPENDIX 10: Pastoral Care Assessment ...........................................................B-71

APPENDIX 11: References ...................................................................................B-77

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ANNEX B to OIF MHAT REPORT

INTRODUCTION

An objective of the Operation Iraqi Freedom (OIF) Mental Health Advisory Team 

(MHAT) was to conduct an assessment of the Army behavioral healthcare system in 

Kuwait and Iraq. The focus was to assess Army wide policies, procedures and resource 

requirements affecting behavioral health (BH) services in theater and provide 

recommendations to address potential organizational and resource limitations. To 

accomplish this goal, MHAT gathered information by utilizing three written surveys (one 

for behavioral healthcare providers, one for unit ministry teams, and another for primary 

medical care providers) and two interview schedules (one for behavioral healthcare 

providers, and one for line leaders). Findings and recommendations are presented first, 

followed by findings and summary of each survey, interview, and data call. See 

Appendices 1 thru 11 for details of the surveys and interview schedules used. 

FINDINGS

1. The closer Soldiers were treated to their units, the more likely they were to 

return to duty. 

Soldiers who were treated by behavioral health providers in division mental health 

sections (DMHS) and the combat stress control (CSC) units averaged a 96% return to 

duty rate. Return to duty rates decreased as the Soldier was treated further back 

through the medical levels of care. 

 

2. There is a lack of systematic training/education in the implementation of 

Combat Operational Stress Control (COSC) Doctrine 

Over half of the 41 behavioral health providers (see Table 1, Appendix 1 for list of BH 

providers) interviewed indicated either they did not know what the COSC doctrine was, 

or did not support it. Further, over half of the BH personnel interviewed reported they 

had not received adequate training in combat stress prior to deployment. Providers 

stated there was a need for more intense training in COSC prior to deployment. 

3. There is no standardized method to collect BH workload and clinical 

information. 

MHAT reviewed several DoD-supported databases and homegrown databases for the 

purpose of calculating the percentage of Soldiers who received BH services and 

returned to duty. No single workload collection system was in place at the beginning of 

hostilities. BH units initially reported workload data using either the Medical Command 

(MEDCOM) supported Disease and Non-Battle Injury (DNBI) report, or the experimental 

Combat/Operational Stress Control Workload and Activity Reporting System (COSCB-3
 

WARS). Nine of seventeen (53%) behavioral health units relied on “homegrown” 

databases for closer workload and patient tracking. 

4. Although the number of BH personnel in theater was sufficient to provide 

coverage throughout the OIF Area of Responsibility (AOR), there were areas in 

theater that lacked BH services. 

While conventional metrics for assessing sufficiency (see Appendix 8) show that BH 

clinical services are meeting Army operational expectations, Soldiers report significant 

unmet behavioral healthcare needs (see Annex A). Some areas had very few or no BH 

services ( ------ Iraq, ------- Kuwait, and in the ------- ), and few of the smaller forward 

operating bases received regular BH outreach services. 

5. BH outreach efforts need improvement to better meet the needs of Soldiers 

and line leaders. 

Soldiers reported unmet needs for behavioral health services, and many did not know 

how to obtain services. Commanders and sergeants were generally happy with the 

support that they received from BH personnel, but reported the time and resources it 

took to take a Soldier to see a behavioral health care provider was excessive. 

Outreach may not be well performed due to a lack of standardized tactics, techniques, 

and procedures (TTP) for assessing needs and ongoing BH requirements of Soldiers 

and units. The MHAT noted that current COSC doctrine does not provide guidance for 

performing needs assessments for units and Soldiers. The absence of an appropriate 

Soldier/unit needs assessment tool prevents local BH leaders from knowing how to best 

allocate their resources. Instead they rely on intuition and anecdotal information. 

Clearly these are not the best guides for medical planning, and can easily lead planners 

to false conclusions. For example, 90% of behavioral health personnel surveyed 

believed Soldiers in their area of operation (AO) had good access to BH services. 

Despite this belief, only 56% of Soldiers surveyed reported knowing how to obtain 

behavioral health care in theater. 

6. Lack of defined standards across the continuum of care from a garrisonbased clinical model of practice to a COSC preventive model. 

Soldiers and units need both preventive and clinical interventions. However, the MHAT 

found that some BH units were inflexible in providing both the clinical and preventive 

services needed by Soldiers in their AOR. These differences exist in part because the 

integration of clinical treatment and preventive interventions is not clearly defined in 

COSC doctrine. 

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7. Inconsistent communication and integration between BH providers and higher 

medical headquarters. 

Thirty-seven (37%) percent of BH personnel reported receiving guidance and adequate 

supervision from their higher headquarters. Thirty-four (34%) percent reported not 

getting needed mission information and intelligence. There were no significant 

differences between the active and reserve components on this issue. Fifty-five (55%) 

percent of the BH officers were dissatisfied with their perceived level of input into 

operational planning. Nineteen (19%) percent of all BH personnel reported having input 

into the policies of their higher command. Command relationships need to be more 

clearly defined. 

8. Shortages of tactical radios and vehicles were an obstacle to conducting 

outreach. 

Seventy-five percent (75%) of the BH officers interviewed in Iraq reported lack of radio, 

phone, and email access significantly impacted their ability to provide outreach services. 

9. Forward-deployed BH units report a greater shortage of psychotropic 

medications than units located in the rear. 

Dissatisfaction with the availability of psychotropic medication was particularly high 

among Combat Stress Control units and Division Mental Health Sections (57.1 & 66.7% 

respectively). Unlike units at higher levels of care, these units did not have an 

integrated pharmacy to immediately dispense medication. Anecdotal reports from 

forward-deployed psychiatrists indicate that filling prescriptions is unnecessarily 

complicated and forces Soldiers and units to arrange at least two convoys. 

RECOMMENDATIONS

Recommendations, supported by the findings, are summarized below. These 

recommendations are separated into two periods of implementation: “Immediate” – 

those recommendations that should be implemented by the current deployed and/or 

recently alerted (OIF2) rotation, and “Future” – those recommendations that will likely 

require more time to implement. 

1. Appoint a Theater/Area of Operation BH consultant to advise the Surgeon on 

BH issues 

a. Immediate Implementation: 

Appoint a BH consultant for each AOR – In order to better allocate BH 

personnel and to oversee the delivery of BH care in the AOR, the commander 

should appoint a BH consultant to each theater/AOR surgeon. This officer may 

be already on staff, or could be requested through personnel channels if a 

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suitable choice is not available. Example duties of the theater/AOR BH 

consultant might include: 

• Conducts a theater/AOR-wide BH needs assessment 

• Establishes BH standards and operational requirements plan 

• Recommends the BH theater/AOR evacuation policy 

• Prepares the BH portion of the medical operations plan 

• Reviews all command/medical policies that affect BH activities 

• Recommends proper distribution of BH units/teams on the battlefield 

• Evaluates the quality of BH services rendered in the AOR 

• Makes regular AOR BH consultant site visits to BH units/teams 

• Coordinates with other BH consultants in adjoining AORs and in the 

primary evacuation chains to ensure unity of effort. 

• Oversees in-theater BH training 

• Coordinates joint and combined BH services where necessary 

• Plans for future BH operations (redeployment surge, etc.) 

• Consults with the Surgeon on all BH matters 

b. Future Implementation: 

(1) Ensure all theaters and AORs have a BH consultant appointed on 

the surgeon’s staff – The creation of a theater BH consultant is not a new 

recommendation. Martin & Fagan (1996) noted problems with integration among BH 

units and missions in the first gulf war, and recommended such a position be created. 

DOD has also directed that each unified command have a BH consultant appointed 

(DODD 6490.5, para 5.5.2). The OTSG BH Consultants can ensure that doctrine and 

policy correctly reflect the duties and responsibilities needed in this vital position. 

(2) Explore consolidation of all active and reserve CSC units into a 

unified training structure – Current Army CSC force structure is composed of 

scattered detachments and companies (see Table 1 next page) reporting to very 

different commands. A unified AC/RC training structure could coordinate CSC service 

provision and standardized training during the readiness phase of the deployment cycle, 

and the cross leveling of resources (personnel and equipment) during the deployment 

phase. 

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Table 1: COSC Units in the U.S. Army

UNITS LOCATION AC AUTH RC AUTH COMMENTS

Active Component Detachments 

24

42 MRI Complete

24

24

Reserve Component Detachments 

24

24

42 MRI Complete

42 MRI Complete

24 Inactivating Now

Reserve Component Companies 

85

85

85

85

2. Conduct an aggressive program of BH outreach. 

a. Immediate Implementation: 

(1) Ensure BH personnel have a regular, far-forward consultation 

program at the small unit level – Behavioral health care providers can reduce and/or 

eliminate many of the barriers to care experienced by Soldiers by physically going to the 

Soldiers who need and/or want help. Further, preventive efforts (classes, command 

consultations, debriefings, unit climate assessments) can only be done through regular 

visits to unit locations. BH personnel must establish a predictable, regular, and visible 

presence at the company/battalion locations.

Although there were sufficient BH personnel in theater to provide needed 

coverage, distribution of BH assets was not optimized. For example, the MHAT found 

that much of ------- Kuwait (------- .) and ------- Iraq (------- ) had no BH prevention services and 

transportation to clinical services required a trip of two or more hours one-way (see 

Appendix 8). 

(2) Increase BH accessibility through liaison with command, UMT 

and primary care personnel – In addition to direct Soldier contacts, BH personnel can 

partner with leaders, commanders, chaplains, and primary medical care providers to 

extend access to BH care. Further, BH personnel need to reach out particularly to 

leaders and other helping professionals as they often have the greatest direct and 

indirect BH stressors (Bourne, Rose, and Mason, 1968). Helping these individuals work 

out their own sleep plans, stress reduction and burnout, should be a vital mission of BH 

prevention efforts (Jones, 1995). 

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(3) Implement a BH reconditioning program – Soldiers should be 

treated as far forward as possible and remain with their units or in proximity to their 

units. Further, Soldiers who are evacuated often receive little or no substantial 

treatment along the evacuation route or at home station (see Evacuation Annex). In 

order to facilitate BH treatment and to minimize BH evacuations out of theater, Soldiers 

with BH (COSC/psychiatric) issues should be kept in theater (Iraq or Kuwait). A 

properly placed, staffed, and operated reconditioning unit could successfully return to 

duty a fair percentage of the Soldiers currently being evacuated for BH reasons. The 

location should be in the rear (for those on weapons restriction), with austere conditions 

(to encourage return to duty), far from towns or other distracters (to minimize 

elopement), and co-located with combat support or combat service support units who 

could profit from the therapeutic work details the Soldiers would provide. 

(4) Ensure adequate BH support for increased demand in services 

during the upcoming battle-handover – Winter/Spring 2004 will be a major upheaval 

as units deploy and redeploy. Post-deployment screening will likely require some BH 

consultation (where Soldiers screen positive on the PDHA BH questions), some units 

may need debriefing sessions, reunion classes, etc. Deploying units may need stress 

management, anger management, communication, suicide prevention, and other 

classes in preparation for the battlefield. 

In addition to deploying and redeploying Soldiers, BH personnel should prepare 

to debrief their returning peers and the other helping personnel (chaplains, chaplain 

assistants, primary care personnel, etc.) who have often vicariously “contained” the 

stresses and pain of others over the course of the deployment. 

b. Future Implementation: 

Train and support a Soldier peer-mentoring program – Since Soldiers 

are much more likely to turn to other Soldiers for support, training Soldiers to provide 

early identification, uncomplicated intervention, and referral will provide better, lessstigmatizing support while extending service availability on the battlefield. This model of 

approach is used successfully by our allies, and U.S. federal, state, and local agencies 

(see Annex A, Appendix 1). BH personnel in support of each unit (DMHS/CSC) should 

be tasked with training and overseeing the peer-mentors in their respective supported 

units. This would minimize cost and maximize the liaison between the supported unit 

and the supporting BH personnel. 

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3. Develop and field standardized tactics, techniques, and procedures(TTPs) for 

BH units and teams 

a. Immediate Implementation: 

(1) AOR BH consultants need to distribute BH appropriately – The 

MHAT noted gaps in BH services in theater. In particular, BH personnel were not 

optimally distributed (see Appendix 8). In order to remediate this, theater BH 

consultants need to review their respective AORs to ensure that BH personnel are 

optimally distributed and that the services rendered provide a consistent network of BH 

services. Where gaps are noted, BH units need to be redirected to provide the needed 

service. 

(2) AOR BH consultants need to ensure BH units/teams have 

appropriate command/support relations with their supported units – Non-divisional 

BH units and teams deployed forward to division and brigade units struggle to be 

accepted and resourced by their supported units. These BH units and teams need to 

have specific, documented command and support relationships (OPCON, attached, 

etc.) to their respective supported combat units in order to clarify their “status.” 

(3) Field a simple, standardized needs assessment tool for Soldiers 

and units – The MHAT noted that few BH personnel had performed a needs

assessment process for their AORs. Creation and distribution of a standardized needs 

assessment tool can provide guidance for BH professionals until a more thorough set of 

assessment TTPs can be created under recommendation 3b(1) below. Such an 

instrument should include symptoms, exposures, morale and cohesion, the desire for 

help, and barriers to care. 

(4) Publish a compendium of “best practices” – The AMEDDC&S or 

the BH section at CHPPM should gather “best practices” and “lessons learned” from BH 

personnel who have recently deployed to OEF or OIF for dissemination to deployed or 

deploying BH personnel. Publication should include website, CD, and limited paper 

media. Contents should include battlefield survival, outreach techniques, command 

consultation, triage, restoration, and other COSC issues. 

(5) Ensure availability of psychotropic medications as far forward as 

possible – CSC providers are rarely located close to pharmacy services, and travel 

between locations in theater is both time consuming and dangerous. In order to 

facilitate proper and timely care, theater medical commanders should either authorize 

psychiatrists and psychiatric nurse practitioners in CSC/DMHS units to possess and 

disburse medication or stock forward support battalions or battalion aid stations located 

closest to BH medical professionals who can prescribe with adequate psychotropic 

medications. 

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b. Future Implementation: 

(1) Develop and field standardized Soldier and unit needs 

assessment tools – Many of the deficits found in theater were due to a lack of proper 

tools and/or guidance. MEDCOM/OTSG should leverage MRMC, AMEDDC&S, 

CHPPM, and other assets to develop and field standardized BH needs assessment 

tools for use by BH personnel in garrison and on the battlefield. 

(2) Update COSC doctrine to better delineate staff and command 

relationships for BH personnel and units – The various divisions command their 

respective DMHSs, while the medical brigade commands the CSC and Combat Support 

Hospital (CSH) units. These separate command structures make it difficult to form a 

seamless BH system. In order to facilitate this, doctrine needs to specify the proper 

command and support relationships among BH units, teams, personnel, and supported 

units. 

(3) Convene a Process Action Team (PAT) to update doctrine and 

procedures for BH units (CSC/DMHS) to possess and disburse psychotropic 

medications – Two-thirds of psychiatrists and psychiatric nurses report there was a 

lack of adequate psychotropics in theater. Many had no access to them because their 

unit was not authorized possession or transportation of medications. Based on a similar 

model to the dental and medical units/teams far forward on the battlefield, CSC and 

DMHS units/teams need to carry a supply of medication with them. 

(4) Publish revised TTPs in COSC technical manual – Although 

general COSC doctrine exists in field manual form, many of the particulars of how to 

implement the doctrine across the deployment continuum of care have not been 

clarified. Tactics, techniques, and procedures (TTPs) – along with appropriate tasks, 

conditions, and standards – need to be developed and published in a COSC technical 

manual. These TTPs will then form the basis for BH “standards of practice” for the 

garrison and deployed environments. Topics should include medication management, 

confidentiality, BH documentation and convenience file (medical records) management, 

scopes of practice for the various disciplines, standards for evacuation, methods for 

needs assessment and evaluation, handling non-voluntary BH evaluations, etc. 

4. Ensure all BH personnel are trained/educated in COSC doctrine, tactics, and 

procedures. 

a. Immediate Implementation: 

(1) AOR BH consultants should establish quarterly BH training 

conferences – Not only did a number of BH personnel state they were under-trained, 

but battlefield execution demonstrated the need for training in COSC doctrine, tactics, 

and techniques. Theater BH consultants should establish regular (quarterly) training 

conferences to ensure that doctrine is clearly disseminated and problems are 

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addressed. Trainings may be centralized, regionalized, or performed via train-thetrainer. Technology may also be leveraged (VTC, telephone, videotape, CD) to 

accomplish this. However, tapes and talk alone will not suffice without some live 

demonstration and periodic oversight. 

(2) Conduct COSC training for BH personnel (AC/RC) preparing to 

deploy – MEDCOM/OTSG and the reserve medical commands should ensure that BH 

personnel (both active and reserve) currently alerted for deployment to theater in 

Spring/Summer 2004 are adequately trained. This could be accomplished by holding a 

predeployment conference or by holding regional training meetings. Holding a 

conference provides the added benefit of allowing the BH personnel to meet each other 

and to begin to plan and network together. 

b. Future Implementation: 

(1) Expand existing Occupational Therapy (OT) COSC course into a 

multidisciplinary course and require attendance of all BH personnel prior to or in 

route to any TOE assignment – The AMEDDC&S currently offers an OT COSC 

course. While this course offers a great platform from which to build, the course must 

be embraced by all of the BH disciplines and be required of all BH personnel, active and 

reserve, to be truly successful as a COSC training program. In addition to active and 

reserve BH personnel, the course should be open to BH personnel from other services 

and departments. 

With the high OPTEMPO, it is essential that all BH personnel attend the COSC course. 

This training could take place during internships, residencies, or the individual’s first 

assignment. Each specialty would be able to flexibly schedule this training into their 

respective educational lifecycle. 

(2) Reorient the AMEDD officer and enlisted military education 

systems to integrate collective blocks of instruction in COSC, disaster mental 

health, and battlefield professional practice – Although some of the BH disciplines 

receive a small block of instruction in COSC, the training is inadequate to properly train 

BH personnel in their vital “go to war” mission. The AMEDD Officer Basic and Advance 

Courses need to be examined to ensure they contain adequate amounts of training in 

COSC TTPs. The COSC Program of Instruction (POI) must also be carefully 

integrated between each course and the revised OT course discussed in 4b(1) above to 

ensure topics are adequately reemphasized yet build on each other. 

 (3) Ensure a COSC/BH track is incorporated into the annual Force 

Health Protection (FHP) Conference – The annual FHP Conference offers a wide 

range of military preventive medicine tracks. COSC (preventive behavioral healthcare) 

is a logical track within the FHP Conference agenda. Courses, workshops, and 

practical offered there would ensure proper sustainment training for both active and 

reserve BH personnel.

. 

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5. Develop & field a data collection methodology for BH surveillance and 

outcome information

a. Immediate Implementation: 

MEDCOM should review the COSC Workload and Activity Reporting 

System (COSC-WARS) for sufficiency and then automate it – Using small-scale 

technologies (Microsoft Access) for common laptop computers and for the Pocket PC 

(handheld) platform, COSC-WARS (revised) could be fielded with the BH providers 

preparing to deploy this coming spring/summer. Although any system devised will 

eventually need to be rolled up into larger DA and DOD systems, COSC-WARS 

(revised) could provide a good interim solution using minimal cost, rapid development 

strategies until these larger systems are fielded. 

b. Future Implementation: 

(1) Integrate COSC prevention efforts into existing and emerging 

theater medical databases – As new medical data systems come on-line, BH 

prevention and clinical efforts need to be captured and tracked. MEDCOM will need to 

track the requirements for automating these reports and ensure that DA/DoD medical 

databases implement these requirements. 

(2) Create a COSC/BH surveillance data repository and analysis 

center IAW DOD Directive 6490.2 and DOD Instruction 6490.3 – In order to better 

understand and ultimately prevent COSC/BH problems, data must be accurately 

collected, stored, and analyzed. The military has made great strides to database 

injuries (Lincoln, Smith & Baker, 2000), but has yet to adequately create or resource a 

BH surveillance system. 

6. Develop a portable digitized BH medical record. 

a. Immediate Implementation: 

AOR BH consultants should publish documentation guidance – The 

MHAT found that BH documentation not only varied from location to location, but was 

often non-existent. Further, documentation was very difficult to transport between levels 

of care. 

To overcome these discrepancies in the near-term, recommend theater BH 

consultants publish guidance to standardize the BH documentation and records 

management process. Specifically, directives should address what forms are used, 

how they are stored, how records are transferred to higher levels of care, and how to 

archive the records when the Soldier and/or medical unit redeploys. 

. 

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b. Future Implementation: 

MEDCOM (in cooperation with Health Affairs and military agencies) 

should develop a field-deployable BH computerized patient record system – Longterm, MEDCOM needs to field a computerized record system (as a module to a larger 

medical system) that satisfies the needs of the behavioral healthcare system in the 

deployed environment. This would include a Soldier-portable medical record (like the 

“personal information carrier” or PIC). 

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PRESENTATION OF DATA THAT SUPPORTS THE FINDINGS

DATA FINDING #1: The closer Soldiers were treated to their units, the more likely 

they were to return to duty. 

Data from COSC-WARS was analyzed to calculate the Soldier return to duty (RTD) rate 

for CJTF-7 Combat Stress Control units. Homegrown databases, that contained 

Soldier contact and evacuation information used by DMHS and the combat support 

hospitals (CSHs), were analyzed to calculate their Soldier RTD rates. The RTD rate 

was calculated by dividing the number of Soldiers returned to duty by the total number 

of Soldiers evaluated during the same time period. When the number of Soldiers who 

returned to duty was not readily available, it was calculated by subtracting the number 

of Soldiers evacuated from the total number of Soldiers evaluated during the same time 

period. The percentages of Soldiers who were treated for behavioral health problems 

and returned to duty (RTD) ranged from 4% to 97%, depending on the type of 

behavioral health unit they were treated in. 

Table 2: OIF Return to Duty 

Type of Unit Unit Dates # Of

Patients

# Of

RTD % RTD

Division Mental 

Health Section ---------- 30 Mar – 6 Sep 03 495 479 97 

Combat Stress 

Control units 

All CJTF-7 CSC 

units 26 Jul – 27 Sep 03 2008 1919 96 

Combat Support 

Hospital (Iraq) 1 Apr – 31 Jul 03 301 209 69 

Combat Support 

Hospital (Kuwait) 12 Mar – 1 Sep 03 229 26 11 

Regional Medical 

Center LRMC 1 Mar – 30 Sep 279* 10 3.6 

* # Of charts reviewed 

(b)(2)

 

 

As a result of the high RTD, both units and Soldiers benefit. Units benefit from 

continued force sustainment and Soldiers avoid the stigma linked to evacuation for a 

behavioral health illness. 

Reasons for a lower percentage of behavioral health Soldiers/patients returned to 

duty at the Combat Support Hospital and Medical Center are not clearly evident from 

this analysis. RTD may be lower because 1) hospital patients are more likely to have 

failed to benefit from outpatient interventions; 2) hospitals were not providing inpatient 

rehabilitation treatment and 3) hospitals have the means to initiate the patient’s 

evacuation to the next echelon of care. 

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DATA FINDING #2: There is a lack of systematic training/education in the 

implementation of CSC Doctrine 

Over half of the BH providers interviewed reported they did not know what COSC 

doctrine was, nor did they support it. Fifty (50%) percent also reported they had not 

received adequate training in combat stress prior to deployment. Results of the BH 

Survey indicated that 57% of the respondents agree that COSC was the best method of 

early intervention, but only 44% of the junior enlisted, 35% of the non commissioned 

officers (NCOs) and 45% of the officers agree that COSC doctrine is relevant to the 

current operation. Sixty nine percent surveyed agreed or strongly agreed they were 

well trained in the six functional areas of CSC prior to deployment. Over 50% of the BH 

providers interviewed stated the need for more intense training in COSC. Findings 

indicate that provider views vary on knowledge and execution of COSC doctrine. This 

was observed in theater, as CSC doctrine was integrated and utilized by some of the 

CSC units but was not followed by others. Providers who are not adequately trained in 

CSC doctrine may not implement CSC concepts or agree to the relevancy of CSC 

doctrine as a treatment method for Soldiers. One cannot determine relevancy of 

doctrine without fully understanding doctrine. 

DATA FINDING #3: No standardized BH data collection methodology. 

Each behavioral health activity in CJTF-7 was directed to enter their workload data into 

the COSC-WARS system and provide this information to the ------- Medical Brigade. 

However, the CSC units used COSC-WARS, the DMHSs input data into the DNBI 

database, and the CSH BH personnel utilized “homegrown” databases. Half (53%) of 

the BH units contacted in theater created and maintained their own “homegrown” 

database systems due to the reported shortfalls within the existing databases. These 

unofficial database systems were used to maintain additional caseload information and 

provide additional workload and Soldier/patient tracking information for the providers 

and also their commands. Maintaining multiple databases created additional work for 

the providers, but this did not detract from their desire to collect data that was valuable 

to their mission. 

DATA FINDING #4: Although the number of BH personnel in theater was 

sufficient to provide coverage throughout the OIF AOR, there were areas in 

theater that lacked BH services. 

To identify the adequacy of behavioral health support (see Appendix 8), the MHAT 

calculated the BH provider to Soldier population ratio for OIF and its collective areas of 

responsibility. The ratio was calculated by dividing the Soldier population of an area of 

responsibility by the number of behavioral health providers supporting that AOR. 

As of September 2003, the OIF ratio was 1 behavioral health provider for every 851 

Soldiers. In Iraq, the ratio was 1 provider for every 830 Soldiers; and in Kuwait, the ratio 

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was 1 provider for every 986 Soldiers. The ratios by area of responsibility ranged from 

no providers for 4,205 Soldiers, to one provider to every 673 Soldiers. 

DATA FINDING #5: BH outreach efforts need improvement to better meet needs 

of Soldiers and line leaders. 

BH personnel’s perception of providing accessible care for Soldiers was different 

compared to the Soldiers who were surveyed. Ninety (90%) percent of the BH 

providers surveyed, agreed that Soldiers in their area of operation had good access to 

BH services. However, only 56% of the Soldiers surveyed reported knowing how to 

obtain behavioral health care in theater. Twenty-six (26%) percent of Soldiers reported 

it would be too difficult to get to behavioral health services. Of the Soldiers who 

screened positive for depression, anxiety, or traumatic stress, 27% reported receiving 

help at any time during the deployment from a behavioral health professional, general 

medical doctor, or chaplain. Of the Soldiers who reported interest in receiving help, only 

32% reported receiving help during the deployment. 

Sixty percent of the respondents to the Soldier well being survey identified command 

stigma (20%), difficulties traveling (20%) and leader/Soldier lack of knowledge about BH 

services and capabilities (20%) as the three top barriers to providing BH care in theater. 

Eight leadership interviews were conducted with battalion (n=7) and brigade (n=1) 

commanders from combat units and four CSM/1SG interviews were conducted as well. 

All the commanders and sergeants indicated that there was enough behavioral health 

services available and that they were generally happy with the support that they 

received. However, they reported that the time and resources it took to take a Soldier to 

see a mental health care provider was excessive. It would take one day or more and 

losing a minimum of an additional Soldier for transportation and security measures. 

DATA FINDING #6: Lack of defined standards across the continuum of care from 

a garrison-based clinical model of practice to a COSC preventive model. 

MHAT found there were operational and doctrinal differences among BH units. 

Interviews indicated providers were divided between the medical and preventive models 

as means of delivering BH services. The reported median time spent doing prevention 

activities was 39% compared to a reported median time of 60% for clinical treatment. 

Eighty-one (81%) percent of the psychiatrists and psychiatric nurses reported spending 

less than half of their time providing COSC prevention. The other BH providers only 

reported spending 50% of their time doing prevention activities. Without instruments to 

assess Soldier/unit needs, BH providers relied on familiar assumptions about needs of 

the community, and on familiar intervention models. Providers with COSC training 

favored preventive strategies to promote wellness in the population – sometimes to the 

exclusion of needed clinical interventions. Providers with medical or clinical 

backgrounds resorted to the “medical model” to evaluate and treat BH disorders in the 

population – to the exclusion of doing preventive outreach and interventions. The 

B-16
 

spectrum of services must to be based on an assessment of the Soldier/unit needs. BH 

personnel who offer both clinical and preventive interventions provide a greater 

continuum of care for the Soldier. 

 

DATA FINDING #7: Inconsistent communication and integration between BH 

providers and higher medical headquarters. 

Thirty-seven (37%) percent of BH personnel reported receiving guidance and adequate 

supervision from their higher headquarters. Thirty-four (34%) percent reported not 

getting needed mission information and intelligence. Fifty-five (55%) percent of the BH 

officers were dissatisfied with their perceived level of input into operational planning, 

and only 19% of all BH personnel reported having input into the policies of their higher 

command. 

DATA FINDING #8. Shortages of tactical radios and vehicles were an obstacle to 

conducting outreach. 

Seventy-five percent (75%) of the BH officers interviewed in Iraq reported lack of radio, 

phone, and email access significantly impacted their ability to provide services to meet 

standards of care. Officers felt these shortages compromised Soldier confidentiality, and 

the ability to receive and give information to the Soldier or the Soldiers’ unit. Shortages 

with SINGARS radios and vehicles made it difficult to meet convoy requirements and 

therefore significantly decreased a units’ ability to provide out reach within its area of 

operation. Some teams were convoying without radios. The lack of email access also 

made it difficult to communicate with units about Soldier issues. This was further 

compounded by a significant number of respondents indicating their unit had few or no 

computers to carry out mission needs. 

Only 49% of the BH providers surveyed agreed that they deployed with enough 

equipment to perform their mission. Officers often brought their own computers and 

supplies to meet mission requirements. 

 

DATA FINDING #9: Forward-deployed BH units report a greater shortage of 

psychotropic medications than units located in the rear. 

Dissatisfaction with the availability of psychotropic medication was particularly high 

between CSC and DMH units (57.1 & 66.7% respectively). For units at higher levels of 

care, particularly those with direct pharmacy support, the dissatisfaction with the 

availability of psychotropic medication was lower. Even so, 50% of psychiatrists and 

nurses at Combat Support Hospitals still reported dissatisfaction with psychotropic 

medication availability. Anecdotal reports indicated that psychotropic medications were 

in short supply during the initial phase of the conflict; that the range of available 

B-17
 

medications was limited to a few selections; and that there was no process to make 

formulary recommendations to the pharmacy before the deployment occurred. 

B-18
 

APPENDIX 1 (Summary of Behavioral Health Survey) to ANNEX B to OIF MHAT 

REPORT 

INTRODUCTION

As part of the Mental Health Advisory Team’s (MHAT) mission to evaluate the 

behavioral healthcare (BH) being rendered in theater, the MHAT devised an anonymous 

questionnaire for BH personnel. 

FINDINGS

1. BH personnel are being utilized in their MOS/AOC. 

Overall, 92% (93% of the officers, 89% of the NCOs, and 96% of the junior 

enlisted) reported they were being utilized in their MOS/AOC. Further, 83% felt they 

had been utilized appropriately. 

2. BH personnel provide suicide prevention training prior to and during 

deployment. 

52% of the active component and 32% of the reserve component BH personnel 

reported active involvement in suicide prevention prior to deployment. 81% of BH 

personnel report active participation in suicide prevention during the current 

deployment. 

3. BH personnel believe Soldiers in their areas of operations have good access 

to BH services. 

90% of the respondents believe Soldiers in their area of operations have good 

access to BH services. Only 2% disagreed with this assessment. Further, 83% of the 

respondents believed that the location of their base of operations was appropriate to 

their mission. 

4. BH personnel generally have good communications with the commanders and 

unit ministry teams (UMT) in their areas of operation. 

65% of the respondents reported good communications with local commanders 

and 71% reported good communications with their local UMT. Only 11% and 8% 

(respectively) felt they had particularly poor communications. And, 82% report that 

commanders in their area of operations actively request BH services. 

B-19
 

5. BH personnel generally feel commanders readily accept return-to-duty (RTD) 

Soldiers back into their units. 

77% of the respondents agreed that commanders readily accept RTD Soldiers

back in their units. However, enlisted BH personnel (70%) were less positive about this 

than the BH officers (84%) (F=4.95; p≤0.03). 

6. Many BH personnel are not well trained in combat and operational stress 

control (COSC). 

31% of the BH personnel were either neutral or reported a lack of training in 

COSC functions prior to deployment. 

7. Lack of needed psychiatric medications in theater (particularly early on in the 

operation). 

Only 36% of the psychiatrists and nurses felt that there was an adequate supply 

of psychiatric medication in theater. 

 8. Many BH personnel lack guidance and support from higher headquarters. 

Only 37% of the respondents reported getting guidance from their higher 

headquarters, and 34% report not getting needed mission information and intelligence. 

In addition, only 37% felt that they received adequate supervision and support from 

higher levels of care. There were no significant differences between components or 

ranks on this issue. 

9. Possible lack of BH input into operational planning and policy.

Only 30% of the respondents felt they had adequate input into operational 

planning. More than half (55%) of the BH officers (and significantly more than the junior 

enlisted) were dissatisfied with their perceived level of input into the operational 

planning. Further, only 19% of all respondents felt that they had input into the policies 

of their higher command. 

10. BH personnel spend significantly more time doing BH clinical activities than 

they spend doing COSC prevention activities. 

Overall, the reported median time spent doing prevention activities was 39% 

compared to a reported median time of 60% doing clinical activities. Only 29% of the 

respondents reported spending more than half of their time doing prevention activities; 

on the other hand, 58% report spending more than half of their time doing clinical 

activities. Further, 81% of the psychiatrists and psychiatric nurses reported spending 

less than half of their time doing COSC prevention activities while only 50% of the other 

BH personnel report spending less than half of their time doing prevention activities. 

B-20
 

11. Many Soldiers who were evacuated should not have been deployed due to 

prior mental health or other problems. 

71% of the respondents felt that many of the Soldiers who ultimately were 

evacuated for behavioral health problems should never have deployed in the first place. 

12. Many BH personnel do not believe that COSC doctrine is the best method of 

early intervention and/or do not believe it is relevant to the current operation. 

Only 57% of the respondents felt that COSC doctrine is the best method of early 

intervention. The officers were more believing than the enlisted. Further, only 38% of 

all respondents felt that COSC doctrine was relevant to the current operation. Indeed, 

nearly half (47%) of the BH NCOs do not feel COSC doctrine is relevant to the current 

operation. 

13. Command stigma, travel difficulties, and leader’s/Soldier’s limited knowledge 

of BH capabilities are the most identified barriers to BH care. 

60% of the respondents identified command stigma (20%), difficulties traveling 

(20%) and leader/Soldier lack of knowledge about BH services and capabilities (20%) 

as the three top barriers to providing BH care in theater. 

METHODS AND PROCEDURES

Study Sample. 

A convenience sample of 116 (77%) of the 155 Army Behavioral Health (BH) 

providers and enlisted Mental Health Specialists in Kuwait and Iraq completed the 

survey between 29 August and 30 September 2003 at 15 locations around theater. 

Some BH providers traveled in from outlying areas to meet with the team, thus more 

than 15 unique locations are actually represented by the data. 

On average, those completing the survey tended to be older (68% aged 30 or 

more), and higher ranking (45% officers) than the Army as a whole. Only 22% were 

junior enlisted Soldiers. Two-thirds (66%) had a college degree, and only two 

individuals (2%) had a GED in lieu of high school diploma. 

The median time in service was 9 years, and the median time served with the 

current unit was only 12 months. 37% of the sample was female, and 38% were racial 

minorities. 56% were Active Component, 7% were National Guard, and 36% were 

Army Reserve Soldiers. 67% of the sample had not deployed prior to OIF. 

Table One shows the types of professionals represented in the survey. 

B-21
 

Table 1: AOCs and MOSs Represented in the BH Survey 

AOC/MOS Description Number 

Percent of 

Respondents 

65A Occupational Therapists 5 4%

66C Psychiatric Nurses 10 9%

60W Psychiatrists 16 13%

73A Social Workers 13 11%

73B Clinical Psychologists 9 8%

91W/91WN3 Health Care Specialists 4 3%

91X Mental Health Specialists 59 50% 

Procedures. 

The MHAT traveled throughout the Kuwait (CFLCC) and Iraq (CJTF-7) 

operational theaters and administered surveys and conducted interviews with BH 

personnel between 27 August and 30 September 2003. All BH personnel contacted by 

the MHAT were asked to complete the survey regardless of their current work 

assignment or unit. 

MHAT personnel administered surveys. All participants were briefed on the 

mission of the MHAT and informed that the survey was both anonymous and voluntary. 

Nearly all BH personnel asked to complete the survey chose to participate. 

Survey Instrument. 

The MHAT members just prior to their deployment to theater constructed the 

survey. No standardized questions were utilized, though most of the questions were 

devised by consensus of the team members. The questions ranged on a variety of 

topics of interest to the MHAT mission, such as utilization, adequacy of care, balance of 

clinical vs. preventive activities, understanding of and compliance with COSC doctrine, 

involvement in suicide prevention and reporting activities, amount of support and 

supervision received, perceived stigma and barriers to mental health care, and 

resourcing deficits. A copy of the instrument can be found at Tab A. 

B-22
 

TAB A: Behavioral Health Provider Survey 

Behavioral Health Provider Survey 

This survey is being done under the auspices of the Army Surgeon General’s OIF Mental Health Advisory Team. 

The purpose of this questionnaire is to gather data about the current mental well-being of Soldiers in theater and the 

functioning of the mental health system in OIF/OEF. Your responses will not be linked to you as an individual. 

Date: ____________________

Age: 

18 – 19

20 – 24

25 – 29

30 – 39

40 or older 

Gender: 

Male 

Female 

Race/Ethnicity: 

Caucasian/White 

African American 

Hispanic 

Asian/Pacific Islander 

Other ___________

Highest Level of

Completed Civilian

Education?

GED 

High School Diploma 

College Graduate

Professional Degree 

Grade/Rank: 

E1 – E4

E5 – E6

E7 – E9

O1 – O3 

O4 – O9 

WO1 – WO5

Primary Component

Active Duty

Reserve 

National Guard 

AGR 

PROFIS? Y / N 

USA / USN / USAF 

How many YEARS have you 

been in the military? If less 

than 1 year, please mark “0”

____________ 

For this deployment, 

indicate month you left 

for

deployment?___________

What is your current unit: 

Division______________

Brigade______________

Battalion_____________

Company____________

How many MONTHS have

you been with your current 

unit? _____________

What is your AOC

/MOS?_______

List your previous 

deployments___________

______________________

______________________

___ 

B-23
 

Behavioral Health Provider Survey 

Please circle the number indicating the degree to which you agree or disagree with the statements below:

Circle 1 if you “Strongly Disagree”, circle 3 if you neither agree or disagree, and circle 5 if you “Strongly Agree” 

1. I was actively involved in suicide prevention prior to deployment. 1 2 3 4 5 

2. I have been actively involved in suicide prevention during deployment. 1 2 3 4 5 

3. What have been the most frequent stressors associated with suicide behaviors (gestures/attempts/ideas): 

1________________ 2_______________ 3________________ 4________________ 5_______________

4. Have there been any completed suicides in your AO? Y / N

5. How many of the completed suicides had sought/received help from BH and/or UMT’s _________ 

6. Soldiers have good access to BH services in my AO. 1 2 3 4 5 

7. What barriers to BH care exist in your AO? ____________________________________________ 

_____________________________________________________________________________________

8. I have good communications with:

Lower Levels of Care 

Higher Levels of Care 

Other BH personnel

Unit Ministry Teams 

Commander’s

Other ________

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

9. My BH team has evaluated _______# of Soldiers each month with suicidal ideation:

 Month 1_____ Month 2_____ Month 3_____ Month 4_____ Month 5_____

 Month 6_____ Month 7_____ Month 8_____ Month 9_____ Month 10_____

10. My BH team has evaluated ________# Soldiers each month for suicide gestures or attempts:

 Month 1_____ Month 2_____ Month 3_____ Month 4_____ Month 5_____

 Month 6_____ Month 7_____ Month 8_____ Month 9_____ Month 10_____

11. What has been the monthly % of Soldiers with suicide-related behaviors referred by: 

 Commanders_____ Unit Ministry Teams_____ Healthcare Providers_____ Soldier Self-referrals_____

12. I routinely review lessons learned with Commanders after suicide attempts and completed suicides. 1 2 3 4 5 

13. I routinely complete ASER’s for suicide attempts and completions. 1 2 3 4 5 

14. What has been the monthly RTD rate for Soldiers seen by your BH team?

 Month 1_____ Month 2_____ Month 3_____ Month 4_____ Month 5_____

 Month 6_____ Month 7_____ Month 8_____ Month 9_____ Month 10_____

15. COMMANDERS READILY ACCEPT RTD SOLDIERS BACK TO THEIR UNITS FROM BH. 1 2 3 4 5 

PLEASE CONTINUE ON NEXT PAGE

B-24
 

16. Please rank order the most frequent reasons that your patients are evac’d to higher Levels of Care? 

___SUICIDAL ___HOMICIDAL ___PSYCHOSIS ___BIPOLAR ___PTSD ___OTHER ANXIETY D/O 

___OTHER AXIS I ___ADMINISTRATIVE ___AXIS II ___OTHER __________; ___ OTHER 

____________; ___ OTHER ___________

17. There has been sufficient holding capability for BH patients in my AO. 1 2 3 4 5 

18. Patient transport among levels of care in my AO has been adequate. 1 2 3 4 5 

19. The location of my BH team has been appropriate for my mission. 1 2 3 4 5 

20. I was well trained in the six functional areas of Combat and Operational Stress Control prior to

deployment.

1 2 3 4 5 

21. Are you currently working in your BH job? Y / N 

22. On average, how many hours have you worked per week in the last month?

23. On average, how many hours have you worked in your MOS/AOC per week in the last month? 

24. I have been appropriately utilized as a BH provider. 1 2 3 4 5 

25. There has been adequate availability of appropriate psychiatric medications. 1 2 3 4 5 

26. What medications have been needed but not available __________; __________; __________; 

__________; __________; __________; __________; __________

27. Laboratory services have been sufficiently available. 1 2 3 4 5 

28. What labs have been needed but not available __________; __________; __________; __________

29. What clinical services have been needed but not available __________; __________; __________; 

30. My BH team deployed with its required personnel. 1 2 3 4 5 

31. My BH team deployed with its required equipment supplies. 1 2 3 4 5 

32. Commander compliance with Command Directed Evaluations is at the same level as prior to deployment. 1 2 3 4 5 

33. My team receives guidance/taskings from my higher HQ. 1 2 3 4 5 

34. My team receives requests for assistance from units in my AO. 1 2 3 4 5 

35. My team receives information and intelligence relevant to our mental health mission. 1 2 3 4 5 

36. My team has input into operational planning. 1 2 3 4 5 

37. My team has input into my higher HQ Command policies. 1 2 3 4 5 

38. My team is able to maintain communication with detached personnel. 1 2 3 4 5 

39. What % of your time is typically spent in _____ Prevention activities; _____ Clinical activities 

40. Please list your major prevention activities __________; __________; __________; __________; 

__________; __________; __________; __________; 

PLEASE CONTINUE ON NEXT PAGE

B-25
 

41. Supervision and support from higher Levels of Care has been adequate. 1 2 3 4 5 

42. I am able to provide treatment on an outpatient basis. 1 2 3 4 5 

43. I am able to monitor treatment progress for my patients. 1 2 3 4 5 

44. Many of the Soldiers who we evacuated should not have been deployed due to prior mental health or other 

problems.

1 2 3 4 5 

45. I believe that the combat/operational stress doctrine is the best method of early intervention. 1 2 3 4 5 

46. The current combat/operational stress control doctrine is relevant to the current operations. 1 2 3 4 5 

For the items below, please circle the number that indicates how often you provide the following actions. 1= 

Never; 2 = Seldom; 3 = Sometimes; 4 = Often; 5 = Always 

47. Our team provides classes and/or briefings to units to help them cope with the stresses of deployment

and/or combat. 

1 2 3 4 5 

48. When visiting units, our team provides informal counseling. 1 2 3 4 5 

49. Our team typically diagnoses a Soldier’s condition during the first visit. 1 2 3 4 5 

50. After a critical event, our team monitors leaders’ actions to insure Soldiers’ physical needs are met (food, 

sleep, hygiene, etc.). 

1 2 3 4 5 

51. Members of our team facilitate debriefings following critical events. 1 2 3 4 5 

52. Our team assists unit leaders to integrate replacements following battle losses. 1 2 3 4 5 

53. Usually, our team refers symptomatic Soldiers to a higher level of care. 1 2 3 4 5 

54. Our team rules out medical causes for Soldier’s mental symptoms. 1 2 3 4 5 

55. Our team treats distressed Soldiers with family or home front problems as mental disorders. 1 2 3 4 5 

56. Our team ensures that each Soldier receives a DSM-IV diagnosis. 1 2 3 4 5 

57. Our team subdues and restrains an agitated Soldier by verbal assurances and reorientation. 1 2 3 4 5 

58. Our team trains to safely control behaviorally disruptive Soldiers who pose a threat to themselves or others. 1 2 3 4 5 

59. Our team provides 24 or more hours of rest, food, hygiene, sleep, and work and relaxing activities for 

Soldiers overwhelmed by combat or operational stress.

1 2 3 4 5 

60. Our team routinely provides medications to Soldiers to help them deal with combat and operational 

stressors. 

1 2 3 4 5 

61. Our team provides a program of treatment (e.g., structured work and multi-modal therapies) to return 

Soldiers to duty that couldn’t return to duty after 3 days. 

1 2 3 4 5 

62. Our team routinely conducts medical consultations to establish a treatment plan. 1 2 3 4 5 

THANK YOU FOR COMPLETING THE SURVEY

B-26
 

APPENDIX 2 (Summary of Primary Care Survey) to ANNEX B to OIF MHAT 

REPORT 

INTRODUCTION

As part of the Mental Health Advisory Team’s (MHAT) mission to evaluate the 

behavioral healthcare (BH) being rendered in theater, the MHAT devised an anonymous 

questionnaire for primary medical care personnel. These personnel were doctors, 

physician assistants, nurses, medics serving in line units, forward support medical 

companies, combat support hospitals, and clinics. 

FINDINGS

1. Primary care personnel generally refer Soldiers with BH issues to a BH 

provider. 

80% of the respondents refer their patients with BH issues to a BH provider. 

20% will refer them to a chaplain, and 10% may treat them directly. This varied by rank. 

Enlisted primary care personnel never treated patients with BH issues themselves, 

while 16% of the officers would treat them directly. 

2. Primary care personnel think units stigmatize their Soldiers with BH problems. 

89% of the respondents reported that line units often or always accept Soldiers 

RTD with medical problems. However, only 53% of the respondents reported that line 

units often or always accept Soldiers RTD with BH problems. While 55% of the junior 

enlisted and 57% of the officers perceive that line units often or always accept Soldiers 

RTD with BH problems, only 39% of the primary care NCOs felt they would be accepted 

back. 

METHODS AND PROCEDURES

Study Sample. 

A convenience sample of 154 Army primary medical care providers and enlisted 

Health Care Specialists in Kuwait and Iraq completed the survey between 29 August 

and 29 September 2003 at 21 locations around theater. 

On average, those completing the survey tended to be older (67% aged 30 or 

more), and higher ranking (55% officers) than the Army as a whole. Only 25% were 

junior enlisted Soldiers. Two-thirds (68%) had a college degree, and only six individuals 

(4%) had a GED in lieu of high school diploma. 

B-27
 

The median time in service was 9 years, and the median time served with the 

current unit was only 8 months. 27% of the sample was female, and 33% were racial 

minorities. 70% were Active Component, 23% were National Guard, and 7% were 

Army Reserve Soldiers. 62% of the sample had not deployed prior to OIF. 

Table One shows the types of professionals represented in the survey. 

Table 1: Professions Represented in the Primary Care Survey

Description Number 

Percent of 

Respondents 

Physicians 34 22%

Physician Assistants 24 16% 

Nurses 18 12%

Health Care Specialists 69 45% 

Other 9 5%

Procedures. 

The MHAT traveled throughout the Kuwait (CFLCC) and Iraq (CJTF-7) 

operational theaters and administered surveys to primary care personnel between 27 

August and 30 September 2003. As the MHAT surveyed Soldiers in line units and BH 

personnel in medical units, they also surveyed available primary care personnel organic 

or attached to these same medical or line units. In most cases, a convenience rather 

than a blank sample was gathered at each unit/site. 

MHAT personnel administered surveys. All participants were briefed on the 

mission of the MHAT and informed that the survey was both anonymous and voluntary. 

Nearly all primary care personnel asked to complete the survey chose to participate. 

Survey Instrument. 

The MHAT members just prior to their deployment to theater constructed the 

survey. No standardized questions were utilized, though most of the questions were 

devised by consensus of the team members. The questions range a variety of topics of 

interest to the MHAT mission, such as utilization, handling of mental health patients, 

referral methods and locations, adequacy of BH care, holding capacity for COSC 

Soldiers, and their sense of perceived stigma and barriers to mental health care. A

copy of the instrument can be found at Tab A. 

B-28
 

TAB A: Primary Care Survey 

PRIMARY CARE SURVEY

This survey is being done under the auspices of the Army Surgeon General’s OIF mental health advisory

team. The purpose of this questionnaire is to gather data about the current mental well-being of Soldiers 

in theater and the functioning of the mental health system in OIF/OEF. Your responses will not be linked 

to you as an individual. 

Date: ____________________ 

Age: 

18 – 19 

20 – 24 

25 – 29 

30 – 39 

40 or older 

Gender: 

Male 

Female 

Race/Ethnicity: 

Caucasian/White 

African American 

Hispanic 

Asian/Pacific Islander 

Other ___________ 

Highest Level of 

Completed Civilian 

Education? 

GED 

High School Diploma 

College Graduate 

Professional Degree

Grade/Rank: 

E1 – E4 

E5 – E6 

E7 – E9 

O1 – O3 

O4 – O9 

WO1 – WO5 

Primary Component 

Active Duty

Reserve 

National Guard 

AGR 

PROFIS? Y / N 

USA / USN / USAF 

How many YEARS have 

you been in the military? 

If less than 1 year, please 

mark “0” ____________ 

For this deployment, 

indicate month you 

left for 

deployment?________

___ 

What is your current 

unit: 

Division___________ 

Brigade___________ 

Battalion __________ 

Company__________ 

How many MONTHS have 

you been with your 

current unit?

_____________ 

What is your AOC 

/MOS?_______ 

List your previous 

deployments________

___________________

___________________

____________

1. On average, how many hours have you worked per week in the last month? ________ 

2. On average, how many hours have you worked per week in your MOS/AOC in the last month? 

________ 

3. On average, how many patients do you see in a week? _________ 

4. On average, what percentage of these patients has mental health issues per week? _______ 

5. What percentage of these mental health patients do you RTD? ________ 

6. What do you do with Soldiers who have mental health issues? 

B-29
 

7. To whom do you typically send a Soldier for mental health issues (Circle One)? 

I treat them Unit leadership Chaplain Mental health (Div) CSC 

CSH/hospital Other ___________________________________ 

8. What do you do with Soldiers who make suicide threats? 

I treat them Unit leadership Chaplain Mental health (Div) CSC 

CSH/hospital Other ___________________________________ 

9. What do you do with Soldiers who make suicide attempts? 

I treat them Unit leadership Chaplain Mental health (Div) CSC 

CSH/hospital Other ___________________________________ 

10. What do you do with Soldiers who make homicidal threats? 

I treat them Unit leadership Chaplain Mental health (Div) CSC 

CSH/hospital Other ___________________________________ 

11. Do you have an SOP for managing suicidal Soldiers (Circle)? Yes No Don’t Know

12. Who are the mental health personnel (units or individuals) that you interact with? 

13. Do these personnel provide sufficient support? If not, what additional support do you need to help 

your Soldiers with mental health issues? 

14. Do you have any holding capacity for Soldiers experiencing combat/operational stress? 

Yes No 

If so, what is your maximum capacity? ________ 

B-30
 

15. How accepting are the line units to having their Soldiers returned to them after being treated for a 

mental health problem (Circle One)?

Never Seldom Somewhat Often Always

16. How accepting are the line units to having their Soldiers returned to them after being treated for a 

medical problem (Circle One)?

Never Seldom Somewhat Often Always

17. Do you document your treatment of MH patients, and if so, where does this documentation go? 

18. Additional Comments? 

Thank You! 

B-31
 

APPENDIX 3 (Summary of Unit Ministry Team (UMT) Survey) to ANNEX B to OIF 

MHAT REPORT 

INTRODUCTION

As part of the Mental Health Advisory Team’s (MHAT) mission to evaluate the 

behavioral healthcare (BH) being rendered in theater, the MHAT devised an anonymous 

questionnaire for unit ministry team (UMT) personnel. These personnel were chaplains 

and chaplain assistants serving in line units, forward support medical companies, and 

combat support hospitals. 

FINDINGS

1. Many UMT personnel are not trained in the Army’s suicide prevention 

program. 

Nearly half (46%) of the UMT personnel have not been trained in the current 

Army suicide intervention techniques; the Applied Suicide Intervention and Skills 

Training (ASIST) or in the Army’s “Menningers” course for UMTs. Significantly more 

active component UMT personnel have been trained in ASIST/Menningers (74%) than 

have reserve component UMT personnel (34%). 

2. Many UMT members conducted suicide prevention training for their units prior 

to deploying. 

69% of the respondents stated they had conducted suicide prevention training for 

their units prior to deployment. Of the 31% who did not, 42% stated they joined the unit 

following deployment, 19% stated that someone else had done the predeployment 

briefings for the unit, and 12% stated that they did not do it predeployment because they 

do it annually or quarterly. Only 15% said that they did not do it because they were too 

busy or didn’t have command support. Most of the training given was given that the 

company (46%) or battalion (34%) level. 

In addition, most (77%) UMT members felt competent in providing a quality unit 

suicide prevention program. Only 4% reported not feeling competent to do so. 

However, the enlisted members and those from the reserve components felt 

significantly less competent than their officer or active component counterparts. 

3. Some commanders have not taken ownership of or are not resourcing their 

unit’s suicide prevention program. 

While 56% of the respondents felt the commander was taking ownership and 

resourcing the unit suicide prevention program, 16% felt the commander was clearly not 

taking ownership of the program; 28% of the respondents felt the commander was only 

B-32
 

lukewarm about the unit suicide prevention program. Enlisted UMT members and those 

from the reserve components feel significantly stronger that their commanders are not 

taking ownership and/or resourcing the suicide prevention program compared with their 

officer or active component counterparts. 

4. Many chaplains do not feel their relationship with their local BH providers is 

functional. 

While only 16% report a poor functioning relationship, only 55% feel they have a 

good one. Further, the enlisted UMT members and those from the reserve components

report a significantly poorer relationship with their local BH provider(s) than their officer 

or active component counterparts. 

5. Uncertain redeployment dates, family separation/problems, and 

command/leadership problems are the three main issues impacting Soldiers. 

Table 1: UMT’s Perception of the Top Five Issues Impacting Soldiers 

Issue Number 

Percent of 

Respondents 

Uncertain Redeployment Dates 53 56% 

Family Separation or Family Problems 42 45% 

Command/Leadership Relations 27 28% 

High OPTEMP / Work Conditions 21 22% 

Communication with Home 19 20% 

6. Better logistical support, certain redeployment dates, and having units fully

staffed with trained UMT members were the top three things that would best 

impact the UMT mission. 

26% of the respondents identified logistical shortages as the single biggest issue 

impacting their UMT mission. UMT members identified the need for items such as 

computers, printers, internet access, phone access, a vehicle, tentage, and religious 

education/family support materials. 

14% of the respondents identified having a certain redeployment date as most 

helpful to their UMT mission. 13% identified having their units fully staffed with 

personnel who are trained and spiritually committed. One division chaplain noted he 

was short 7 battalion chaplains at the time of the survey. 

7. UMT members identified other chaplains, family, and other Soldiers as their 

primary source of personal support. 

38% of the UMT members reported another chaplain as a source of support, 

25% identified family as a source of support, and 21% reported other Soldiers as a 

source of support. 13% of the UMTs identified God as a source of personal support. 

B-33
 

METHODS AND PROCEDURES

Study Sample. 

A convenience sample of 94 UMT members (Army chaplains and enlisted 

chaplain assistants) in Kuwait and Iraq completed the survey between 29 August and 

25 September 2003 at 23 locations around theater. In addition, a number of UMT 

members were canvassed during routine UMT training meetings in both Kuwait and 

Iraq, thus more than 23 locations are actually represented. 

Two-thirds (66%) of the respondents were commissioned chaplains, 15% were 

chaplain assistant NCOs, and the rest (19%) were junior enlisted chaplain assistants. 

Of the officers, about half (52%) were field grade officers. 52% were Active 

Component, 12% were National Guard, and 35% were Army Reserve Soldiers. Further, 

active component officers were significantly junior in rank to the reserve component 

officers. Time in theater ranged from 14 days to 365 days, with a median of 159 days. 

Table 2 shows the types of units the respondents supported in theater. 

Table 2: Types of Units Supported by UMT Personnel 

Description Number 

Percent of 

Respondents 

Combat Units 26 28% 

Combat Support Units 29 31% 

Combat Service Support Logistics Units 28 30% 

Combat Service Support Medical Units 11 12% 

Procedures. 

The MHAT traveled throughout the Kuwait (CFLCC) and Iraq (CJTF-7) 

operational theaters and administered surveys to UMT personnel between 29 August 

and 25 September 2003. As the MHAT surveyed Soldiers in line units and BH 

personnel in medical units, they also surveyed available UMT personnel organic or 

attached to these same medical or line units. In most cases, a convenience rather than 

a blank sample was gathered at each unit/site. 

Surveys were administered by MHAT personnel. All participants were briefed on 

the mission of the MHAT and informed that the survey was both anonymous and 

voluntary. Nearly all UMT personnel asked to complete the survey chose to participate. 

B-34
 

Survey Instrument. 

The MHAT members just prior to their deployment to theater constructed the 

survey. No standardized questions were utilized, though most of the questions were 

devised by consensus of the team members. The questions range a variety of topics of 

interest to the MHAT mission, such as the quality of the suicide prevention programs 

within units, the relationship UMT members have with BH personnel, and what UMT 

members perceive as the major issues impacting Soldiers. A copy of the instrument 

can be found at Tab A. 

B-35
 

TAB A: Unit Ministry Team (UMT) Survey

OIF UMT SURVEY

The survey is being done under the auspices of the Army Surgeon General’s OIF mental health 

advisory team. The purpose of the questionnaire is to gather data about the current mental wellbeing of Soldiers in theater and the functioning of the mental health system in OIF/OEF. Your 

responses will not be linked to you as an individual. 

Your Rank: _______________ Your Component (Circle): Active Reserve Guard 

Date: _____________ Date You Arrived in Theater (this deployment): ________________ 

Type of Unit Supported: Combat Combat Service Support (Medical) 

 Combat Support Combat Service Support (Logistics) 

1. Have you received either Menninger or ASIST training (circle)? Yes No 

2. How competent do you feel in providing a quality suicide prevention program for your 

unit (circle): 

Very Good 1 2 3 4 5 6 7 8 9 Very Poor 

3. Did you conduct pre-deployment suicide prevention briefings for the unit? Yes No 

a. If Yes, at what level? Squad Platoon Company Battalion Other 

b. If No, why not? ______________________________________________________ 

4. How well do you feel your commander has taken ownership of the program and used 

command influence to resource it?

 Extremely well 1 2 3 4 5 6 7 8 9 Not at all 

5. How functional would you say your relationship is with your local mental health care 

provider(s)? 

Extremely functional 1 2 3 4 5 6 7 8 9 Very Poor 

6. What are the three biggest issues that impact your Soldiers (use back if needed)? 

7. What one think would make the biggest positive impact on your unit ministry mission? 

8. Who do YOU turn to for personal support? 

B-36
 

APPENDIX 4 (Summary of Behavioral Health Interviews) to ANNEX B to OIF MHAT 

REPORT 

INTRODUCTION

Face to face interviews with behavioral health professional (officer) and 

paraprofessional (enlisted, NCOs) personnel from CFLIC (Kuwait) and CJTF-7 (Iraq) 

were conducted to obtain level of perspectives on the delivery, resources and problems 

encountered providing mental health/behavioral health care in a combat operational 

theater. The professional behavioral health field is comprised of five specialties: 

psychiatry, psychology, social work, psychiatric nursing, and occupational therapy. 

KEY THEMES

1. Resource issues impact delivery and quality of care. 

Professional and paraprofessional behavioral health providers listed the lack of 

or absence of communication devices (telephone, SINGARS radio), vehicles, and 

computers as a key obstacle in providing quality care. 

2. Provider views vary on services offered for their area. 

Providers are divided between the medical model and prevention as a means of 

delivering services to Soldiers. 

3. Provider views vary on knowledge and execution of COSC doctrine. 

Over half of the providers indicated they either did not know what the COSC 

doctrine was or they did not support it. 

4. Providers indicate a need for training in COSC. 

Over half of the professional and paraprofessionals’ interviewed stated they had 

not received adequate training in combat stress prior to deployment. Providers stated 

the need for more intense training in COSC. 

B-37
 

APPROACH

Face-to-Face Interviews. 

Members of the MHAT team conducted all interviews. Forty-one interviews were 

conducted at fourteen different locations throughout the Kuwait and Iraq area of 

operations with the following group composition: 

Field grade 12 (29%) 

Company grade 15 (37%) 

NCO 7 (17%)

Junior Enlisted 7 (17%) 

Themes/Questions. 

Prior to all interviews, key themes and specific questions were determined that 

every MHAT interviewer would attempt to address. All individuals were asked the same 

questions. Below are the specific themes and questions for all interviews. 

Themes: Resources, Soldier problems, clinical activates, documentation, and 

knowledge of Combat Operational Stress Control (COSC). Interview questions included: 

(1) what resources do you lack to conduct your mission? How does it impact? (2) What 

are the most frequent Soldier problems your team/unit encounter? (3) What have been 

your unit’s/team’s most effective prevention activities? How do you know? (4) What 

have been your unit’s/team’s least effective prevention activities? How do you know? (5) 

What have been your unit’s/team’s most effective clinical activities? How do you know? 

(6) What have been your unit’s team least effective clinical activities? How do you 

know? (7) Have you had to change your SOP’s for this deployment? If so, why? (8) How 

does your unit/team respond to Critical Events (i.e. Soldier casualties, suicides, 

accidents)? (9) Is your clinical documentation: electronic/paper/none//stored with 

you/stays with Soldier. (10) What do you think are your unit’s/team’s most effective 

suicide prevention activities? (11) How do you manage Soldiers who are dangerous to 

self and/or others? (12) How do you monitor clinical activities? (13) How does your 

unit/team implement the six functional areas of COSC? (14) How well did the 

combat/operational stress guidelines you read or were taught apply to the current 

operations? (15) How could the guidelines or training be improved? (16) Describe your 

processes for maintaining patient confidentiality. (17) Have you provided care to 

detainees/civilians? If so, have you had adequate training and resources for this? 

B-38
 

Procedures. 

All interviews began with member of the MHAT interview team introducing 

him/her self and describing the purpose and objective of the interview. Confidentiality 

and anonymity were guaranteed in order to encourage candid and honest discussion. 

Thus, no names of any of the interviewee’s were recorded. All interviews lasted 

approximately 60 minutes. 

RESULTS

Enlisted Behavioral Health Specialists (91X) in Iraq 

There were ten NCOs and junior enlisted in the CJTF-7 AO, three females and 

seven males. There were another eight Soldiers identified in the “comments” section as 

being present for several of the individual interviews. Only two Soldiers identified having 

prior deployment experience. Under the heading ‘resources’, several respondents 

indicated manning was an issue for their organization. Several respondents from the 

same unit indicated that they came to the theater short a few people and have since lost 

an additional five personnel. (100% manned equals 23). This shortage coupled with 

additional duties tasked for the junior enlisted created problems in the unit delivering 

services to other units. “ We are tasked out with many things in the AO and are not able 

to get our main job’s done. KP, guard duty, and other duties keep us out of the job 2-3 

days a week....it impacted the prevention team make-up and we are short one 

Prevention Team. At least one member of each of the five separate behavioral health 

organizations represented indicated that the units’ computers were an issue. Several 

indicated the computers were not configured to meet the unit needs and required 

reconfiguration to accomplish the mission. Several units also indicated that they did not 

have computers to provide their teams (most BH units had teams spread out around the 

theater) and therefore the teams were not able to enter into and report data on the 

COSC-WARS reporting system. Teams also were not able to enter patient/client data 

electronically. Communications was an issue for most respondents. Several reported 

only one SINGARS for their unit “Went 1 1⁄2 months with no communication with our 

outlying prevention teams.” The limited number of SINGARS radios also presented 

problems for unit ability to convoy (convoys require three vehicles, two vehicles with 

SINGARS). Several individuals indicated their unit did not have DSN/telephone 

capability. This created two problems from their perspective; units served could not 

contact them for ‘requests for service’, and, a compromise of patient confidentiality 

(team members would have to borrow the use of another units phone, often without the 

ability to speak in private). Only one member reported the absence of medications as a 

problem for his unit. Half of the individuals indicated they did not have and adequate 

number of vehicles to carry out their mission. Several members also indicated that the 

B-39
 

vehicles were not adequately armored to provide protection for the teams while on the 

road and were concerned about the safety of their team members. 

Two issues were reported by at least half of those interviewed as frequent 

concerns of Soldiers. (1) Family issues, i.e.; money health, infidelity, or loneliness. (2) 

Conflicts with leadership. Several 91Xs reported that Soldiers were voicing concerns 

about safety while convoying, “...service members are scared on convoy(s).” “...IEDs, 

RPG and ambushes are the major concerns in reference to Soldier well being.” Other 

frequent issues included; prior behavioral health issues resurfacing, deployment length 

and uncertain return home date, symptom complaints (sleep, irritability, depressed), 

battle fatigue and combat operational stress issues. Other concerns reported by at least 

one Soldier: “homicide” (specifics are not available), “handling human remains”, and 

lack of knowledge in combat operational stress procedures by leaders and Soldiers (it 

was unclear if this was a behavioral health provider shortcoming or the units serviced) 

The most frequently reported effective prevention activity listed by 91Xs was 

“walk about and sector sweeps” (going into another units AO and engaging with 

Soldiers). Soldiers (91X) involved in these activities report; lower rates of use for mental 

health services in their AO, higher level of recognition on return to the unit serviced, and 

increased acceptability of mental health services by Soldiers and command. 

Interviewees also reported psycho-educational classes and debriefing as effective 

interventions. Only two Soldiers, both from the same behavioral health organization, 

reported “walk about” and classes, as ineffective, preferring to utilize a garrison style 

clinic approach. (These two Soldiers were members of a unit whose commander did not 

support any MH functions in theater other than clinical operations).

Least effective prevention activities were limited to specific class offerings, i.e.; “ 

What to do when you get a dear John letter” or “guided imagery”. One Soldier who 

identified “walk about” as most effective also indicated it as least effective, “ units blow 

us off until they need us.” One Soldier indicated OT, as a function was ineffective but 

related the failure to lack of OT supplies to carry out a successful mission. 

Most Soldiers interviewed agreed that one on one intervention was their most 

effective clinical intervention. Those Soldiers endorsing one to one felt it was related to 

the ability to provide a “safe and confidential ‘ place for Soldiers to tell their problems. 

Nearly half of the 91Xs interviewed endorsed medication management and psychoeducational classes as an effective clinical operation. 

One Soldier felt the “Fitness Center” run by the unit was very effective at 

returning Soldiers to duty. 

There was no strongly endorsed “least effective clinical “ function reported. 

Individuals reporting problems indicated the following: getting Soldiers into the CSH for 

holding, intervening too soon after a crisis (“Maybe we should wait the 48-72 hours as 

based on doctrine”), switching back and forth between prevention and clinical activities, 

Soldiers “bored with suicide awareness training”, inability to provide consistent follow-up 

with the same provider, and using restoration as a treatment intervention. The 

B-40
 

interviewee stated that Soldiers placed in restoration failed because the Soldier knew 

that the next step was hospitalization and then “a ticket home”. 

Seventy percent of the 91Xs interviewed indicated either they were not aware 

any SOP for their unit or did not respond to the question of an SOP. Of the three 91Xs 

responding, all indicated they felt FM 8-51 did not adequately address the problems 

they viewed as important. One Soldier indicated that FM 8-51 and HQ SOPs were too 

rigidly applied and tied the hands of Soldiers to do the job effectively. The collective 

responses of the 91X indicate possible problems with; clearly understanding FM 8-

51doctrine or ambiguities within doctrine, insufficient supporting SOPs for theater 

events, or a failure to embrace doctrine as a means of addressing combat operational 

stressors. 

All respondents reported Critical Event Debriefing as non-problematic. Only two 

Soldiers from the same organization reported the ability to do documentation 

electronically. One solder reported his unit had run out of forms and had no means 

available to copy or reproduce additional forms. All individuals indicated they gave a 

copy of the intervention activity to the Soldier and kept a record for the unit. Unit plans 

for managing records after returning to home station were not clear. One Soldier 

indicated his unit planned to burn all records. 

Soldiers interviewed indicated that suicide education classes were their units’ 

most effective intervention for suicide. They also listed as safety contracts and unit 

watch as other successful intervention practices. They varied on responses for 

management of dangerous patients. Most responded that dangerous Soldiers were 

referred to the CSH for possible hospitalization. Some indicated UCMJ action, removal 

of weapons or limited access to weapons as intervention steps. 

Less than half of the 91Xs interviewed indicated that they had knowledge of or 

used COSC functions/doctrine. Of the four Soldiers who indicated they knew and used

doctrine, two indicated it was either “not appropriate for this battle” or applied it too 

rigidly, “We only do prevention” Two Soldiers from the same unit have consistently 

responded throughout the interview process that their unit only does clinical functions 

and that CSC does not apply to their mission in the theater and that it does not work 

when they have attempted to use it. These two Soldiers have also indicated that their 

unit did not provide or emphasize CSC training in the pre-deployment phase of the unit. 

Several Soldiers indicated that they have never received training in combat operational 

stress guidelines since entering into their field one Soldier indicated he had only worked 

in TDA assignments. 

The majority of 91Xs felt training in COSC were either non-existent or grossly 

inadequate to prepare them for their mission. Several indicated that while in the garrison 

setting the emphasis is on “other” duties, i.e., motor stables, etc., at the expense of 

learning their MOS duties and functions. The problem was severe enough for several of 

them that they felt they did not know how to adequately do their job in theater. Many of 

the Soldiers requested that more time and more thorough training be given to them. 

B-41
 

All Soldiers indicated that confidentiality issues were discussed with Soldiers 

seen in their areas. Several indicated that any files maintained by their organization 

were kept secured. With respect to intervening with civilians, only two responded that 

they had performed any interventions. No solider acknowledged having any training in 

dealing with civilians, either allies or Iraqi. 

Additional comments included; “there is no place for me to go when I need 

someone to talk to.” “Command had lectured them on sucking it up and doing the right 

thing until the Commander learned we weren’t going home for sometime. Then they 

broke down and cried, after this things loosened up a bit...” This comment was made in 

the context of the unit’s productivity for seeing Soldiers. 

Behavioral Health Officers in Iraq 

A total of twenty-one company grade and field grade mental health officers were 

interviewed. Seventeen were male, four female, including one female officer from the 

USAF. Nine officers were field grade rank. The officers represented eleven different 

units located at twelve separate locations. The full range of behavioral health specialties 

was represented. Three officers indicated they had previous deployment experience. 

Approximately 75% of the officers responded that communications problems; i.e., 

phones, SINGARS, and email access, significantly impacted their ability to provide 

services that would meet standard of care. Officers felt these shortages compromised 

Soldier confidentiality, and the ability to receive and give information to the Soldier or 

the Soldiers’ unit. “Command is not providing input because they can’t call us to 

discuss the Soldier. Soldiers just show up cold.” The only USAF officer seeing Army 

Soldiers stated, “ No way to contact Army leaders about the Soldiers referred to me 

from the -------------------- by their medical teams and chaplains. The Army units lack 

phones and email. They talk of a ‘green phone’, but I don’t know what it is or how to 

access it. The impact is, I can’t hear the leaders’ side of what the Soldier tells me, or 

advise them on how to help the Soldier.” Shortages with SINGARS radios made it 

difficult to meet convoy requirements and therefore significantly decreased a units’ 

ability to do out reach within its AO. The lack of email access also made it difficult to 

communicate with units about Soldier issues. This was further compounded by a 

significant number of respondents indicating their unit had few or no computers to carry 

out mission needs. “I spent over a thousand dollars of my own money to get the needed 

supplies for this mission. I bought my own printer.” Another officer indicated the 

shortage of email access/computers necessitated his using his own personal “MWR 

email time allocation” to do official business such as mail reports to higher 

headquarters, or communicate with units about a Soldier. Other concerns reported that 

impacted mission capability included shortages or no access to medications, a 

particular problem for CSC units (medication is not listed in their MTOE, however they 

see sufficient numbers of Soldiers requiring medication maintenance). The lack of 

vehicles also reduced the ability to successfully do out reach within the units AO. 

Staffing shortages caused when the CSHs did split operations impacted the ability to 

provide a NP unit at the CSH. Several providers felt this impacted their ability to hold 

B-42
 

patients or do effective administrative evaluations ultimately creating premature or 

excessive evacuation from theater. 

Nearly two thirds of those interviewed listed home front issues, i.e.: family 

problems, infidelity, missing family or key events, money, etc, as a frequent complaint 

for Soldiers. Approximately half listed; leadership, unknown return home or length of 

deployment, problems with peers or unit, prior psychiatric problems, and combat 

operational stressors as frequently heard Soldier concerns. Other problems listed 

included; occupational, fatigue from duties, family support groups, and Soldiers with 

self-harm incidents. 

Half of the officers indicated that “walk about” or presence in the unit was their 

most effective method. “We know because patients and commanders are willing to 

convoy two hours to see us.” “Soldiers coming to me in D-Fac.” Several units indicated 

they did not do or see prevention as being their mission, “We don’t do prevention, but 

focus on mental health care.” “No proactive outreach program.” Half of the officers also 

endorsed psycho-education classes as being very effective. “”Prevention classes, 

actually showed decrease in cases after classes outreach to units.” Several officers 

indicated unit surveys or an assessment of the unit was beneficial and well received by 

commands. “After providing a unit assessment, we would print up a document with 

assessment findings and recommendations. This was well received by commands.” 

The majority of respondents indicated no response or no problem for “least 

effective” prevention activity. One officer indicated the absence of medication up to July 

created problems with preventing further psychiatric complications. “No meds available 

– particularly for Soldiers needing refills. We only started to get meds in July (at the 

CSH). Prior to this, we had to send troops all the way to Kuwait on C-130 hops to get 

their meds refilled. We need to deploy with a med chest full of psych meds.” The Air 

Force mental health officer indicated problems with communicating with officers and 

getting them to understand the issues. “ The Army leaders seem to understand battle 

stress, but not family problems or anything else. In the Air Force, no commander has 

ever second-guessed me. Here, with the Army, their reaction is “Suck it up; it’s a war.... 

I wish I could contact the commanders and get them to be more supportive.” Other 

responses included; “we don’t do formal CEDs, we abandoned that.”, “Stress classes 

become ‘complaining sessions’. 

Clinical activities, either successful or unsuccessful, did not elicit overwhelming

response for any single factor. There were a total of four favorable responses for one to 

one intervention and psycho-education classes. Other positive clinical activities eliciting 

3 or fewer responses are: presence/availability, CED, fitness program, or traditional 

style mental health services. Negative clinical activities with fewer than three responses 

included: “clinic mentality”, psychotherapy, “holding patients too long in theater”, set 

schedule, and pressure to provide a diagnosis. 

Responses from participants on changing SOPs included eight who said they 

had changed their SOPs, and six who said they either did not have an SOP or they 

B-43
 

were not aware of having an SOP for their unit. Reasons for changing SOPs included: 

changing operational environment, problems between CSC and DMH, flexibility or 

rigidity in the application of prevention vs. restoration activities. One officer indicated a 

change was needed to counter the impact of the ‘MRI CSH’ doctrine change.

Apparently the MRI CSH was resistant to admitting actively suicidal patients. This 

resistance to admitting forced the mental health unit to provide a means of keeping and 

watching the Soldier, something the unit was not resourced for. Another officer indicated 

a need to write an SOP to counter units sending home Soldiers for home front stressors 

without seeking mental health guidance first. This BH officer was concerned about the 

possibility of another Ft. Bragg type occurrence. 

All officers responding indicated they have been doing CEDs and felt they were 

favorably received by command. Several indicated they had modified the application to 

meet their perceived needs. 

Only three officers indicated they could keep records electronically. Interviewees

were evenly divided between sending the record exclusively with the Soldier or giving 

the Soldier a copy and maintaining a copy with the BH unit. Over half indicated they 

sent a copy with the Soldier when the Soldier was air evacuated. Several officers 

indicated they had not kept any written record of prevention interactions though they 

indicated they had concerns about ‘standard of care’ or licensure issues’. Several 

officers indicated a shortage of paper made it difficult to provide documentation. 

Slightly less than half of the behavioral health officers indicated suicide 

prevention classes as their most effective intervention. Several indicated they did not do 

suicide prevention because they viewed it as a chaplain program. “We have also been 

instructed not to do suicide prevention programs (because it was the chaplains). Three 

officers from other units indicated they did suicide prevention because the chaplain in 

their AO was not doing suicide prevention or did it poorly. Responses for intervention to 

dangerous Soldiers included taking the Soldiers weapon away (8 respondents), unit 

watch (3 respondents) and talk therapy (6 respondents). 

Half of the behavioral health providers indicated they monitored clinical outcomes 

through follow-ups with Soldiers. Most indicated this was a difficult task because of 

theater constraints. Several officers indicated they could not or did not measure 

outcomes because Soldiers did not return to them or could not be located after the 

provider saw the Soldier. Several indicated in this section of the interview and other 

sections of the interview that Soldiers sent to the hospital were often lost through the 

evacuation system. Providers attributed this loss to the Soldier’s knowledge that once 

he/she made it to the hospital, they had a ticket home and were no longer invested in 

getting better. 

Responses to how well the individual or unit was implementing the six functional 

areas of COSC were divided between ‘not applying to me’ and ‘doing it well’. Only one 

third of the officers made comments relating to training or preparation for the 

deployment. All respondents indicated they were not adequately trained to perform this 

B-44
 

mission. “ I was told by a superior, ‘don’t worry about it; you’ll get training when you 

arrive.’ I didn’t.” Another commented, “This is not the place to train us – we should be 

trained well before deployment.” Several officers felt command and control issues for 

BH units needed improvement. Other comments included; improve mental health 

capability in the CSH (felt it lead to higher evacuation rates), behavioral health 

professionals inappropriately utilized in the preventions role, doctrine or the application 

of doctrine needs to be more flexible for the theater. 

Confidentiality issues are handled either through minimal record keeping, locking 

records up at the unit, or providing limited feed back to the Soldiers’ commander 

Only a few respondents indicated they had worked with civilians, either 

contractors or Iraq nationals. Approximately one third of all interviewees did not feel 

adequately prepared to work with foreign nationals. 

Additional comments made by the behavioral health officers included: “We need 

crew served weapons to meet the convoy requirements.” “The convoy requirements 

restrict our ability to get out and perform the mission.” There were two providers who 

indicated shortages or limited access to medication made it more difficult to perform the 

mission. 

Enlisted Behavioral Health Specialists (91X) in Kuwait 

Four male junior enlisted and NCOs 91X ‘s were interviewed in the CFLCC 

theater of operations. Interviews were conducted with two separate units at two 

separate locations. Both NCOs had prior deployment experience. Length of time 

deployed ranged from six months to nine months. 

The group listed ‘lack of vehicles’ and manpower shortages (one group was short 

8 personnel) as key resource problems. Communications and limited medications were 

also noted. 

Home front problems and problems with unit leadership, were listed by all 

respondents as the most frequently relayed issues for Soldiers. 

Only one Soldier indicated his unit did prevention activities, psycho-education 

classes. One Soldier whose organization did not do prevention commented, “We only 

do mental health.” Only one Soldier responded that his units prevention program did 

something that was perceived to be negative. “Anger management didn’t work. The 

same Soldiers kept coming back.” 

The 91Xs stated the most positive clinical activities as one to one interventions 

and ‘running an out patient clinic or walk in clinic. “Soldiers tell their peers and they 

come in to see us.” One Soldier indicated as an effective clinic function his units’ 

‘Smoking Cessation Program’ (arguably a prevention program). The least effective 

B-45
 

clinical function was only identified by one Soldier, “Staffing cases with credentialed 

providers.” 

Two individuals from the same unit indicated their unit had SOPs and had 

changed them as a result of the unit locating in a fixed facility. Only one Soldier had 

been involved in performing a Critical Event Debriefing. 

Charting for all Soldiers was done on paper. All indicated that the write up went 

with the Soldier. The unit would only keep a copy if the Soldier was going to be 

evacuated. 

Three respondents indicated their unit did suicide prevention classes with one 

Soldier commenting that his unit had Soldiers screened with the “Beck Depression 

Scale”. One Soldier stated his unit did nothing. Management of dangerous patients was 

done with line of sight (3 respondents), unit watch and removing weapons (one 

respondent). Only one Soldier indicated his unit was involved in monitoring clinical 

outcomes. One Soldier responded with, “No follow up has ever been done.” 

All Soldiers responded to the questions of implementation of COCS and 

guidelines for COSC as not applying to their unit or mission. For suggestions on how to 

improve COSC, Soldiers replied more training was needed. “We don’t spend anytime on 

our week end drill doing COSC.” This was a similar complaint from both reserve and 

active units in Iraq. Several complained that when in garrison or on week end drill the 

only thing they do is ‘motor stables’. 

Confidentiality was ensured by keeping separate from medical records, 

maintaining records in a locked area, and by providing a private location for interviews. 

No one reported having interactions with civilians or foreign nationals. There were no 

additional comments made. 

Behavioral Health Officers in Kuwait 

There were six officers interviewed in CFLCC, four male and two female. The 

officers represented a full range of behavior health specialties. Two officers had 

previous deployment experience. One officer had only been deployed for 2 months; the 

rest had been deployed for at least six months. 

Resource shortages varied among officers. Two responded with vehicles and 

medications (initially) as a problem. One officer was new and unfamiliar to military 

psychiatry implying that his lack of knowledge created a resource problem. One officer 

indicated that dispersal of manpower resources created a shortage of services in some 

areas. 

Three fourths of the officers reported home-front issues as the leading complaint 

from Soldiers. Leadership, boredom/no sense of purpose, and return home dates were 

B-46
 

identified by one third of the officers interviewed. Other issues included low emotional 

preparation, symptom complaints, and suicidal thinking. 

Half the officers stated their most effective prevention activity is doing psychoeducation classes. Other interventions included giving out GTA cards on prevention 

subjects and doing the Beck Depression Screening test for Soldiers coming into sick 

call. Least effective measures included ‘being stuck in the medical model’, and sending 

Soldiers to the rear from Iraq (to Kuwait). ‘They only want to hang out at the pool and lift 

weights’. 

Effective clinical measures did not elicit multiple responses. Providers felt having 

a clinic, holding one to one therapy, and the ability to hold patients for seven days were 

the most effective interventions. Least effective included attempts to ‘reintegrate 

Soldiers into their unit, and communication with other mental health providers. 

Two thirds of the providers did not mention the use of SOPs for their 

organization. One responded the SOP s had been changed to reflect emergency 

procedures. Providers also indicated limited use and/or acceptance of Critical Event 

Debriefings.

All providers stated their documentation was done on paper. A copy went to the 

Soldier and some providers maintained a copy at the unit they were at. One 

organization developed their own database to keep track of workload and patient 

events. 

Half the providers used psycho-education classes for suicide intervention. PRN 

hospitalization was also seen as an effective intervention. Management of dangerous 

patients was also handled by admitting for over half of the respondents. One third had 

used unit watch as a means of intervention. 

All of the providers indicated the measurement of clinical outcomes for their unit 

was either ’very difficult’ or was not being done. “A problem...Get nothing back from 

those who are referred on. Even the ------ doesn’t notify us. For RTDs, no news is good 

news.” 

All providers indicated they had not implemented COSC functions into their AO. 

Over half felt the COSC doctrine was not appropriate for their AO. “We’re too far back, 

and too late.” Suggestions for improvement ranged from increased formal training to 

conferences or panel discussion at the BH Science short course. 

The majority of respondents used ‘consent forms’ and securing files as means of 

maintaining confidentiality. One third of the officers had some exposure to Iraqi citizens 

as part of their clinical work experience. All felt that training and preparation were 

inadequate for the task. 

B-47
 

Additional comments included the need for communication between CFLCC and 

CJTF-7 mental health professionals to coordinate treatment activities. One provider also 

indicated that they needed better training in fragmented orders (FRGs). 

B-48
 

APPENDIX 5 (Summary of Line Leaders Interviews) to ANNEX B to OIF MHAT 

REPORT 

INTRODUCTION

One-on-one interviews with battalion and brigade commanders in CJTF-7 (Iraq) 

and CFLCC (Kuwait) were conducted. The commanders were from both combat and 

combat support/combat service support units. The selection of commanders was based 

on whether companies in their units were identified to complete the Soldier health and 

well-being survey. 

KEY THEMES

1. Morale is low, but improving.

Commanders and Senior NCOs reported morale was low, but that it was improving as 

MWR improved. R&R and mid-tour leave was identified as positively affecting morale. 

2. The behavioral out-reach effort needed to be improved. 

All the commanders and sergeants indicated that there was enough mental health 

services available and that they were generally happy with the support that they 

received. However, the time and resources it took to take a Soldier to see a mental 

health care provider was excessive. 

3. In-theatre behavioral health training is possible. 

There was an expressed desire to have all mandatory re-deployment training conducted 

in theatre, as opposed to conducting the training at home station. The sergeants 

believed that in-theatre training was possible as long as it was adequately planned and 

coordinated. 

APPROACH

Procedures. 

All interviews were conducted by a member of the MHAT team. Interviews 

began with an introduction and a description of the purpose and objective of the 

interview. Confidentiality and anonymity were assured. Thus, no names of any of the 

interviewee’s were recorded. All interviews lasted approximately 60 minutes. Forty-one 

interviews were conducted at fourteen different locations throughout the Kuwait and Iraq 

area of operations with the following group composition: 

Battalion/Brigade Commanders 8 Combat Arms 

B-49
 

CSM/1SG 4 Combat Arms

Themes/Questions. 

Prior to all interviews, key themes and specific questions were identified for the 

MHAT interviewer to address. All individuals were asked the same general questions. 

Below are the specific themes and questions for all interviews. 

Themes/Questions: How are Soldiers doing? What people or programs are 

available to assist you in decreasing the stressors your Soldiers face? How do you 

refer your Soldiers to receive mental health? How feasible is it to conduct training in 

your area of operations? What resources do you have available for Soldiers that need a 

break (for example, sending Soldiers to the rear for R&R)? 

RESULTS

Battalion/Brigade Commanders of Combat Units 

A total of 8 interviews were conducted with battalion (n = 7) and brigade (n = 1) 

commanders from combat units. Overall, the commanders believed that low morale 

was an issue, but they felt it was improving as quality of life was improving. All the 

commanders reported that the uncertain redeployment date was a huge stressor on 

Soldiers and families, with the re-deployment date changing numerous times. One 

commander noted that the FRGs were effective in dispelling rumors about the return 

date. Other stressors reported by commanders included the combat environment they 

were in, which occurs on a daily basis; changes in officer leadership due to attendance 

at military schools; and brigade polices that “don’t make any sense.” One battalion 

commander noted that many Soldiers believe that the brigade commander doesn’t care 

about them. Regarding mental health assets, all the commanders stated that there 

were enough mental health personnel, and overall, their relationship with mental health 

was good. However, many commanders believed that mental health personnel needed 

to do a better job of coming out to the units. Several commanders noted that they lose 

at least two Soldiers every time they send one to mental health because of required 

escort, as well as Soldiers required to conduct the convoy. Commanders wanted as 

many mandatory re-deployment classes conducted in country rather than waiting to 

conduct them in garrison. The commanders also mentioned the R&R and the mid-tour 

leave programs. The commanders all felt these were good programs, but expressed 

concern that only about 40% of their Soldiers would be able to participate in at least one 

of them, with the other 60% not being able to go on R&R or take mid-tour leave. 

B-50
 

Sergeants First Class/First Sergeants of Combat Units 

Two Sergeants First Class and two First Sergeants were interviewed from 

combat units. All these sergeants reported that their Soldiers were tired and that morale 

was low. All four sergeants reported poor phone and mail service. There was general 

anger over not being able to communicate with families back home. In general, these 

sergeants reported that MWR was improving, but it still had a ways to go. Overall, 

these sergeants felt that there were sufficient mental health services available, but that 

the time it took to take a Soldier to see mental health was excessive. Three of the four 

sergeants stated that there needed to be a better outreach program. One sergeant 

noted that when the mental health officer did visit the base camp that he was only able 

to see one-third of the Soldiers who wanted help because of the limited time available. 

Another sergeant noted that they rely on the chaplain for mental health services. The 

key Soldier stressors identified by these sergeants included: family problems, financial 

issues, and uncertain re-deployment date. Two of these sergeants were also 

concerned about how Soldiers would respond during the holiday season and not being 

with their families. All of these sergeants believed that in-theatre mental health training 

was possible as long as it was appropriately planned and coordinated. All the 

sergeants reported that their units participated in R&R and mid-tour leave. 

B-51
 

APPENDIX 6 (Summary of Behavioral Health Unit Data Calls) to ANNEX B to OIF 

MHAT REPORT 

INTRODUCTION

As part of the Mental Health Advisory Team’s (MHAT) mission to evaluate the 

behavioral healthcare (BH) being rendered in theater, the MHAT devised a data call 

matrix in order to gather data from the various BH units throughout theater. These units 

included combat stress detachments/companies, division mental health sections, and 

combat support hospital psychiatric sections. The data from these various units were 

compared and contrasted. 

FINDINGS

1. Behavioral health assets had high RTD rates. 

All behavioral health assets in CJTF-7, CSH, CSC, and DMHS, experienced high RTD 

rates ranging from 73% to 100%. 

2. Reported early shortages of psychotropic medications resolved. 

Thirteen of seventeen (76%) behavioral health units or slices of units report psychiatric 

medications are not currently a problem. Only three of the reporting units indicated they 

had brought medication with them to the theater at the start of the war. Thirteen of the 

units reporting indicate that they have regularly used medication as part of their 

treatment regime while deployed. 

3. A universally accepted tracking system for relevant behavioral health data 

does not exist. 

Half of the behavioral health units or slice elements report the need to develop their own 

“home grown” data collection system to keep track of workload and medically relevant 

data. Only three of the seventeen units reporting indicated they track suicide 

information. 

METHODS AND PROCEDURES

Study Sample. 

All major behavioral health units in theater were queried via telephone, email, 

and/or in-person between 29 August and 2 October 2003. Although some smaller, 

B-52
 

forward-located prevention teams were not canvassed, all parent organizations and 

major slices were contacted. Units contacted are listed in Table 1 below. 

Table 1: Units Participating in MHAT Data Call 

Unit Type of Unit Location

------------------------------------------- Combat Support Hospital -------------------------

------------------------------------------- CSC Unit -------------------------

------------------------------------------- CSC Unit -------------------------

------------------------------------------- Psychiatric Section, ASMB -------------------------

------------------------------------------- Combat Support Hospital -------------------------

------------------------------------------- CSC Unit -------------------------

------------------------------------------- Combat Support Hospital -------------------------

------------------------------------------- Division Mental Health Section -------------------------

------------------------------------------- Combat Support Hospital -------------------------

------------------------------------------- CSC Unit -------------------------

------------------------------------------- CSC Unit -------------------------

------------------------------------------- Combat Support Hospital -------------------------

------------------------------------------- Division Mental Health Section -------------------------

------------------------------------------- CSC Unit -------------------------

------------------------------------------- CSC Unit -------------------------

------------------------------------------- Division Mental Health Section -------------------------

------------------------------------------- Combat Support Hospital -------------------------

Procedures. 

The MHAT traveled throughout the Kuwait (CFLCC) and Iraq (CJTF-7) 

operational theaters interviewing and surveying BH personnel. In addition, the MHAT 

gathered utilization, medication, documentation, and other unit data. Data was 

gathered via telephone, email, and in-person during MHAT visits to the units. 

Data was collected in matrix form. The MHAT then tabulated, compared and 

contrasted the data. 

Survey Instrument. 

The matrix was constructed by the MHAT members following their deployment to 

theater. No standardized questions, matrices or frameworks were utilized, though most 

of the questions were devised by consensus of the team members. The questions 

range on a variety of topics of interest to the MHAT mission, such as utilization, 

handling of mental health patients, documentation methods, reporting methods, 

medication availability, suicide tracking, etc. A list of the questions can be found at Tab 

A. 

B-53
 

TAB A: Data Matrix Questions 

Unit 

Type of Unit 

Location 

• What is the unit’s BH holding capacity? 

• What is the unit’s BH return to duty (RTD) rate? 

• What is the unit’s BH evacuation rate? 

• How many BH providers are present in the unit? 

• How many BH providers are authorized on the unit MTOE? 

• How many Soldiers does your unit support? 

• Do you have a locally developed database to track your patients/activities? 

• When a patient is evacuated, with whom do you send the clinical/admin 

paperwork? 

• When a patient is evacuated, does the unit keep a copy of the clinical/admin 

paperwork? 

• How many (if any) of those who completed suicide in your unit’s area of 

operation were receiving BH treatment? 

• How many (if any) of those who attempted suicide in your unit’s area of operation 

were receiving BH treatment? 

• How many suicidal patients has your unit treated? 

• Does you unit have a suicide tracking system? 

• Does you unit use COSC-WARS to track activities? 

• Are psychotropic medications available in your unit? 

• Did your unit bring psychotropic medications with you into theater? 

• Did your unit need psychotropic medication at all? 

• What psychotropic medications do your unit need? 

• Does your unit have a formulary? 

• Is the unit’s current psychological testing kit adequate? 

• Did your unit have adequate laboratory support? 

B-54
 

APPENDIX 7 (Summary of Fort Stewart Data) to ANNEX B to OIF MHAT REPORT 

PURPOSE 

The MHAT visited Fort Stewart to review the impact of the 3rd ID deployment to 

OIF deployment on the behavioral healthcare system. 

METHODOLOGY 

 Interviews with key informants, review of behavioral health clinical files, review of 

patient administration databases. 

FINDINGS

1. Soldiers returning from OIF for behavioral health problems had good access to 

follow-up care. 

Details of home station disposition of Soldiers who returned to Ft. Stewart for behavioral 

health reasons are reviewed in the Evacuation Annex. To summarize, of the number 

(49) of Soldiers who returned to Ft. Stewart from deployment to Iraq or Kuwait for 

behavioral health reasons, 84% (41) followed up with behavioral health services upon 

their return. The median number of visits to behavioral health was four. Out of the 

group of behavioral health returnees, only three returned as psychiatric inpatients. The 

Ft. Stewart MEDDAC was well prepared to receive and follow Soldiers who returned for 

behavioral health problems, or who sought behavioral health services upon their return 

to Ft. Stewart. The majority (83%) of the returnees were seen within one week of their 

return, although the clinic had capacity to provide unlimited daily walk-in evaluations in 

addition to scheduled appointments. 

2. U.S. Army Reserve and National Guard Soldiers became a significant new

beneficiary population for behavioral health services at Ft. Stewart. This caused 

a sustained reduction in family member behavioral health services. 

Ft. Stewart is a power projection platform and in essence has become the home station 

for thousands of mobilizing and demobilizing Reserve Component (RC) Soldiers. RC 

Soldiers who utilized behavioral health services while at Ft. Stewart became a new 

beneficiary group for the MEDDAC and competed with availability of BH services for 

family members. Normally, the majority of patients seen at the MEDDAC for behavioral 

health services are non-active beneficiaries since the 3ID Division Mental Health 

Section provides care for most of the Ft. Stewart active duty Soldiers. As 3ID Mental 

Health prepared to Kuwait, the MEDDAC Behavioral Health Department assumed 

responsibility for active duty behavioral health care. Services were curtailed for nonactive duty beneficiaries but anticipated to resume once 3ID deployed. The demand for 

behavioral health services by active duty personnel did not abate as expected but 

continued to grow progressively. The proportion of active duty contacts in the 

B-55
 

Behavioral Health Clinic was 23% during October 2002, but grew steadily by month to 

achieve a high of 92% in August 2003 primarily due to activated RC personnel. The 

number dropped in September to 80% and may continue to drop as the 3ID Mental 

Health Section resumes clinical operations. The number of non-active duty 

appointments was reduced, and child services were sharply curtailed. Contracts for 

additional providers had been approved and new hiring actions had been initiated. 

3. The redeployment of 3ID was associated with a spike in psychiatric inpatient 

admissions approximately 30 days after redeployment. 

The average monthly census for inpatient psychiatry from September 2002 to August 

2003 was four patients per day. In September 2003 the average daily census climbed 

to eight patients per day. Between 3 Aug - 13 Oct 03, 33 Soldiers who had deployed to 

OIF had been admitted for inpatient psychiatric treatment. Of these 33 patients, 70% 

(23) were considered by the staff to be admitted for reasons that were directly related to 

their OIF deployment, primarily depression, post-traumatic stress, and adjustment 

problems. 

4. Aggressive behavioral health screening was conducted with redeploying OIF 

Soldiers. Nearly 500 Soldiers were connected with follow-up assistance based on 

this screening initiative. 

Approximately 13,000-14,000 Soldiers redeploying to Ft. Stewart were screened with a 

questionnaire that identified behavioral health concerns. A behavioral health provider 

reviewed the completed questionnaire with each Soldier, and where indicated, made a 

formal or informal referral to a behavioral health or community agency. A sample 1,339 

completed screening forms were reviewed to determine screening outcomes. Of those 

screened, 6% (approximately 840) were referred for follow-up assistance. Of those 

referred, 58% (approximately 487) followed up with the agency to which they were 

referred. These results indicate that nearly 500 Soldiers were offered and accepted 

assistance reported behavioral health concerns identified from screening. 

5. The current division surgeon and two Bde surgeons support the concept of 

assigning BH teams to each BCT. 

The 3rd is currently undergoing reorganization from three BCTs to five BCTs. The 

Division Surgeon and both of the BCT surgeons interviewed support the concept of 

having BH teams assigned to each of the BCTs. The current number of BH officers 

assigned to the division is not enough to support the current 3-Bde configuration. 

Additional BH officers will be needed to support the new 5-Bde configuration. The 

division surgeon has submitted an unmet requirement for 3 additional social work (73A) 

or psychology (73B) officers. 

In addition, the two interviewed Bde surgeons and the 5 interviewed BN PAs stated that 

the minimum rank for the mental health specialists (91Xs) should be Sergeant (E5) due 

to the needed skill level and maturity to perform their mission. 

B-56
 

6. The two Bde surgeons and the five Bn PAs from the 3rd ID recommend giving 

battalion aid stations a basic load of psychotropic medications. 

All of the primary care providers interviewed at the 3rd ID (2 Bde surgeons and 5 Bn 

PAs) reported that they needed psychotropic medications – particularly SSRIs, nonSSRI antidepressants, and sleeps aids – at the battalion aid stations during OIF. They 

recommend that these medications be part of their basic load of medications for all 

deployments. 

B-57
 

APPENDIX 8 (Distribution of BH Services) to ANNEX B to OIF MHAT REPORT 

INTRODUCTION

As part of the OIF Mental Health Advisory Team’s (MHAT) mission to evaluate 

the behavioral healthcare (BH) being rendered in the OIF theater, the MHAT examined 

BH staffing and distribution. In particular: Are there enough BH personnel in theater to 

successfully accomplish the BH mission? Are the BH personnel/units adequately 

distributed throughout theater in order to successfully execute the BH service mission? 

 

In order to answer these questions the MHAT generated a layout of the BH 

resources in theater (as of mid-Sep 03) and examined a number of possible methods 

for estimating the need for and positioning of BH personnel. Finally, the MHAT 

considered various evaluation strategies for each estimation method. The details of this 

analysis are in the discussion following the findings and recommendations generated by 

the analysis. 

Due to the constant changing battlefield and the concomitant shifts in personnel, 

the validity of parts of this analysis is very time limited. The data gathered for this 

analysis took place between 27 August and 2 October 2003. For convenience, midSeptember 2003 will be used as the target date. Changes made following midSeptember are not reflected in this analysis. Further, data on several variables were 

sketchy and often unverifiable. Findings and recommendations may be influenced by 

these considerations and should thus be judged in this light. 

FINDINGS

1. Although the number of BH personnel in theater was sufficient to provide 

coverage throughout the OIF Area of Responsibility (AOR), there were areas in 

theater that lacked BH services. 

While conventional metrics for assessing sufficiency show that BH clinical services are 

meeting Army operational expectations, however, Soldiers report significant unmet 

behavioral healthcare needs (see Annex A). Some areas had very few or no BH 

services (-------- Iraq, -------- Kuwait, and in the -------- ), and few of the smaller forward 

operating bases received regular BH outreach services. 

Table 2 lists the numbers of BH personnel in each of the respective areas (Kuwait and -------- Iraq). This shows that there are several zones with little or no BH support (see 

Figure 1). The numbers of Soldiers in Table 2 have been rounded to the nearest 1000 

for security purposes, however, there are very likely greater numbers of Soldiers in each 

area than listed since truck drivers and other support personnel actually living in one 

region may be assigned to a unit that is based in another region. Further, special 

operators were not listed in the numbers provided to MHAT. 

B-58
 

Table 2: Regional BH Personnel to Soldier Ratios

(Number of Soldiers rounded to nearest 1000 for OpSec) 

UNIT BH SOLDIERS RATIO

 

GRAND TOTAL 163 138000 846 

B-59
 B-60

Figure 1: Map of Iraq as of mid-Sep 2003 

(b)(2)
 

2. BH assets were fielded doctrinally under-strength and therefore in an 

“economy of force” mode.

Although the divisions deployed with their organic BH assets, the 4th ID deployed 

without its social work officer (33% of their professional staffing). The CSHs conducted 

split-based operations, which reduced their ability to effectively provide BH services. 

The ------- had an operational BH section, but the ------- only had a single psych nurse 

assigned who was chief of an intermediate care ward. The -------- -------- had a single 

psychiatrist and a single 91X who was not being used in her MOS. The -------- had no BH 

assets and utilized part of the ------- and a fitness team from the ------- in that role. 

According to FM 8-55, the basis of allocation for CSC detachments is 1 per division or 1 

per 2-3 separate brigades. CSC companies are allocated 0.5 per division (see Table 1). 

Table 2 below lists the basis of allocation for fitness and prevention teams, the actual 

number on hand, and differences. Based on this analysis, CSC units are short 3 fitness 

teams and 2 prevention teams. However, when calculated based on maneuver unit 

requirements, there are sufficient fitness teams, but a shortage of 4 prevention teams. 

This seems to support what the MHAT noted in theater: there were sufficient restoration 

resources, but a lack of outreach services. 

Table 1: CSC Unit Base TOE (Fitness and Prevention Teams) 

Unit Basis of Allocation On-Hand Missing 

Unit TOE Fit Prev Fit Prev Fit Prev 

----- CSC Det MF2K 1 3 0 3 -1 0 

----- CSC Det MRI 2 4 1 3 -1 -1 

------- CSC Det MF2K 1 3 1 3 0 0 

------- CSC Co 4 6 3 5 -1 -1 

TOTAL 8 16 5 14 -3 -2 

Table 2: Doctrinal Distribution for CSC Teams (Fitness and Prevention Teams) 

AORs Basis of Allocation On-Hand Missing 

Unit BCTs Fit Prev Fit Prev Fit Prev 

101st ABN Div 3 1 3 1 3 0 0 

4th ID* 4 1.5 4.5 2 4 0.5 -0.5 

3rd ACR 1 0.5 1.5 0 2 -0.5 0.5 

1st AD** 5 2 6 2 5 0 -1 

5th Corps*** N/A 4 6 N/A N/A N/A N/A 

TOTAL 13 9 21 5 14 -4 -7 

• Includes ------- . 

• ** Includes ------- . 

*** The Corps is allocated one CSC company to cover non-divisional units. 

Outreach and far-forward stationing will be critical in some units if Soldiers are to 

receive BH services. Mental health or CSC teams were located at most of the 

maneuver brigade/ACR medical companies, but only because they were augmented 

with external BH assets. The ------- and the ------- both controlled sizeable tracts of land 

B-61
 

and troops, but have no organic BH personnel. Although they were to be augmented by 

a single prevention team each, two were needed to cover the ------- that was responsible 

to cover the vast western region; more were probably needed. In the -------, there was 

only one prevention team from the -------- that visited occasionally. They had no CSH, or 

DMHS support within a two-hour drive. The -------- did receive local outpatient and brief 

inpatient support from a USAF social worker at the small ASAF medical treatment 

facility at the airfield. 

 

Table 3 lists all of the units in OIF that had BH personnel organic to them. Outside of 

the CSC and DMHS units, BH personnel were scattered in amongst the medical 

personnel – perhaps without much central direction or support as noted in the BH 

Survey findings (see Appendix 1). 

Table 3: BH Units in OIF in mid-September 2003 

UNIT LOCATION COMMENTS

Medical Brigade Psych Staff 

------- Med Bde ------- Kuwait Medical C2 for CFLCC AOR 

----- Med Bde ----------------- Iraq Medical C2 for CJTF-7 AOR 

Combat Stress Control Units 

------- Med Det -------- Iraq 

----- Med Det (MRI) ----------------- Short 1 Fitness Team and 1 Prev Team 

----- Med Det (MF2k) --------- Iraq Short 1 Fitness Team 

------- Med Co ----------------- Iraq Short 1 Fitness Team and 1 Prev Team

Combat Support Hospital Psychiatric Sections 

----- CSH (North) --------- Iraq No BH assets (used 98th CSC)

----- CSH (South) -------------- Iraq Only 1 (psychiatrist) working in BH 

----- CSH (North) ------------- Iraq 1 Psych Nurse (working Med-Surg) 

----- CSH (South) ----------------- Iraq Inpt ward, but only stabilization services 

----- CSH ----------------- Kuwait Local outpt; Inpt only for evacuation 

------- CSH ---------------- Kuwait Minimal local outpatient through clinics 

Division MH Sections 

---- AD DMHS -------------- Iraq 

---- ID DMHS ------------- Iraq Short its social work officer 

------- ABN DMHS --------- Iraq 

Area Support Medical Battalion Psych Sections 

------- ASMB --------- Kuwait One social worker 

------- ASMB -------------- Iraq One psychiatric PA 

as of 15 Sep 03 

3. There is sufficient CSC holding capacity except in Kuwait. 

Each fitness team (3 officers + 7 enlisted) can care for approximately 25 ambulatory, 

non-psychotic, Soldiers. The MHAT noted that the daily average census at the 

restoration units was between 2-5, some reported surges reaching 9-12. However, 

Kuwait (and -------- Iraq) had no restoration or reconditioning functions. For the most part, 

B-62
 

BH units in Kuwait chose to perform outpatient therapy with local Soldiers and to 

continue to evacuate to the rear those Soldiers evacuated from Iraq (as noted by the 

low 11% RTD in Kuwait). 

The ------- that arrived in CFLCC about 10 March was attached to CJTF-7 during the 

ground offensive, deployed into Iraq in early April, and was redeployed to CONUS and 

inactivated in June 03. CFLCC has had only the holding capacity of a clinic staffed by 

the ------- and what could be provided at the -------. Table 4 lists the BH holding capacity in 

Kuwait. 

 

Table 4: BH Holding Capacity in Kuwait 

UNIT LOCATIONS PSYCHIATRIC STAFF 

Northern Camps North Kuwait None

----- CSH --------------- 8-12 beds

------- CSH --------------- None

------- Clinic ---------------- Minimal overnight holding

-------- Clinic -------- --------

 ASMB - minimal overnight holding

4. All CSC restoration capacity was in the Divisions’ rear areas and near CSH 

assets. 

The MHAT noted that all five CSC fitness teams were located in the divisional support 

areas and often located close to a CSH (see Table 1). Collocating the CSC fitness 

teams with the CSHs was implemented in various ways, but was not done on the basis 

of a proper mission analysis. The ----- CSC became the BH clinic within the ----t CSH 

with whom they were collocated. The ----- and the ------ CSC fitness teams purposely 

positioned themselves away from the CSHs (though on the same camp) in order to 

maintain their autonomy and to “de-pathologize” the restoration process. 

Table 1: CSC Fitness Team Locations

DIVISION AREA OF 

RESPONSIBILITY LOCATION PARENT UNIT NEARBY CSH 

101st ABN Div Support Area ------------------ ----- CSC Co ----- CSH ------- 

4TH ID Support Area -------------------------- ---- CSC ----- CSH ------- 

4th ID ----------------- Support Area ----------------------------- ----- CSC Co ----- CSH --------

1st AD near Division HQ and AVN Bde ------------------------------------ ----- CSC Det

1st AD AOR ----------------------------- ----- CSC Co ----- CSH --------

5. Time-distance under tactical conditions present significant barriers to care.

The MHAT observed that convoy procedures (requirements for two or more persons per 

vehicle, three vehicles in a convoy, front and rear vehicles equipped with functioning 

radios, and at least one crew-served weapon in the convoy – manned by a non-medical 

MOS Soldier) present a significant barrier to mobility. Further, many of the brigade 

B-63
 

combat teams and battalions had dispersed their subordinate units over wide tracts of 

land in small forward operating bases (FOBs). This dispersion added to difficult mobility 

made outreach very difficult throughout the CJTF-7 AOR. Kuwait also had mobility 

problems. In order to leave certain camps in Kuwait, one was required to either have a 

colonel (O6) in the vehicle or have a specific memo from a colonel (O6) each time one 

left the camp. 

Alternative means of consultation were also difficult because of telecommunication 

shortages and poor reliability. Conversely, line units have the same or larger costs to 

bring overstressed Soldiers to the BH teams’ base areas or to communicate with BH 

personnel.

RECOMMENDATIONS

1. Appoint a Theater/Area of Operation BH consultant to advise the Surgeon on 

BH issues.

In order to better allocate BH personnel and to oversee the delivery of BH care in the 

AOR, the commander should appoint a BH consultant to each theater/AOR surgeon. 

This officer may be already on staff, or could be requested through personnel channels 

if a suitable choice is not available. Important aspects of this positions should include 

conducting a theater/AOR-wide BH needs assessment and recommending to the 

commander(s) a proper distribution of BH units/teams on the battlefield. 

2. AOR BH consultant need to distribute BH to sufficiently cover service gaps. 

The MHAT noted gaps in BH services in theater. In particular, BH personnel were not 

optimally distributed. In order to remediate this, theater BH consultants need to review 

their respective AORs to ensure that BH personnel are optimally distributed and that the 

services rendered provide a consistent network of BH services. Where gaps are noted, 

BH units need to be redirected to provide the needed service. Because of the 

dispersion-mobility problems, it may enhance outreach to forward locate small teams at 

more of the FOBs and then have them coordinate to cover one or two other nearby 

FOBs. The more BH personnel are forward located, the less the mobility problem will 

influence the mission. 

3. Utilize fitness team personnel to provide local outreach. 

Fitness team officers of all specialties and the mental health and occupational therapy 

enlisted should provide aggressive outreach and preventive education to units in the 

same camp when their restoration duties allow. Fitness team personnel can also be 

reconfigured into prevention teams or augment existing prevention teams. 

B-64
 

APPENDIX 9 (Psychotropic Medication Issues) to ANNEX B to OIF MHAT REPORT 

INTRODUCTION

The MHAT sought to clarify questions related to the availability of psychotropic 

medications in OIF. In particular: 

1. Is there a shortage or unavailability of psychotropic medications? 

2. What psychotropic medications should be available on the formulary? 

3. Is laboratory support sufficient to support psychiatric evaluations and 

treatment? 

4. How have psychotropic medication shortages (if any) been managed by 

behavioral health units? 

FINDINGS

DATA Finding #1: Forward deployed behavioral health units report greater 

dissatisfaction with the availability of psychotropic medications, than units 

located in the rear. 

Dissatisfaction with the availability of psychotropic medication was particularly high 

among Combat Stress Control units and Division Mental Health Sections (57.1 & 66.7% 

respectively). Unlike units at higher levels of care, these units do not have an integrated 

pharmacy to immediately dispense medication. Anecdotal reports from forwarddeployed psychiatrists indicate that filling prescriptions is unnecessarily complicated by 

forcing Soldiers and units to arrange at least two convoys – one for the Soldier’s 

medication evaluation and prescription, and another for the medication pick-up at the 

nearest pharmacy. 

Despite these concerns, forward deployed psychiatrists were not able to provide 

concrete evidence that their patients were less compliant with medications, had failed to 

fill prescriptions, were prematurely evacuated, or had suffered a bad medical outcome 

due to difficulty in acquiring psychotropic medications. 

For units at higher levels of care, particularly those with direct pharmacy support, the 

dissatisfaction with the availability of psychotropic medication was lower. Even so, 50% 

psychiatrists and nurses at Combat Support Hospitals still reported dissatisfaction with 

psychotropic medication availability. 

Anecdotal reports indicated that psychotropic medications were in short supply during 

the initial phase of the conflict; that the range of available medications was limited to a 

few selections; and that there was no process to make formulary recommendations to 

the pharmacy before the deployment occurred. 

B-65
 

DATA Finding #2: Behavioral health units need a broader range of 

antidepressant and sleeping medications. The addition of stimulants to the 

 formulary is requested. 

Fifty percent (50%) of the surveyed psychiatrists identified a need for a broader range of 

antidepressant medications in the current formularies, and 33% indicated that additional 

sleeping agents and stimulants would be helpful for treating patients. 

DATA Finding #3: To overcome anticipated psychotropic medication shortages, 

some DMHS and CSC units deployed with unregulated medications. 

Although the intent was to enhance patient care, 25% of forward deployed behavioral 

health units dispensed psychotropic medications from unregulated medication 

stockpiles. How these stockpiles were initially obtained is unclear. There did not 

appear to be adequate medication formularies or dispensing records. 

Poor visibility in this matter creates an unnecessary liability for the provider and theater 

medical command. It is unclear which medications are available, how many are 

stockpiled, where they are being stored, and to whom they are being dispensed. Side 

effects and adverse medication outcomes cannot be adequately tracked. 

RECOMMENDATIONS

Immediate implementation: 

(1) Ensure availability of psychotropic medications as far forward as 

possible – CSC providers are rarely located close to pharmacy services, and travel 

between locations in theater is both time consuming and dangerous. In order to 

facilitate proper and timely care, theater medical commanders should either authorize 

psychiatrists and psychiatric nurse practitioners in CSC/DMHS units to possess and 

disburse medication or stock forward support battalions or battalion aid stations located 

closest to BH medical prescribers with adequate psychotropic medications to support 

these providers. If BH providers are authorized to possess and disburse psychotropic 

medications from their units, proper procedures should be implemented to regulate this 

process. 

(2) Ensure BH Input into Formulary Recommendations – The BH consultants 

to the CFLCC and CJTF-7 Surgeons should encourage development of processes by 

which psychiatrists, psychiatric PAs and nurse practitioners in far forward units (DMHS, 

CSC, and ASMBs) can request additions and changes to the formularies of supporting 

pharmacies. 

(3) Broaden Current Formularies – Broaden the current pharmacy formularies 

to include SSRIs, non-SSRIs, and several sleeping medications. At a minimum, the 

formulary should include these additional medications: 

B-66
 

Table 1: Recommended Additions To CSH Formularies 

SSRI Non-SSRI Sleeping Agent 

Fluoxetine 

(Prozac)

Venlafaxine

(Effexor) 

Trazodone 

(Desyrel) 

Paroxetine

(Paxil) 

Bupropion

(Wellbutrin) 

Zolpidem Tartrate 

(Ambien) 

Sertraline 

(Zoloft) 

Clonazepam 

(Klonopin) 

Citalopram Hydrobromide 

(Celexa) 

Or 

Escitalopram Oxalate 

(Lexapro) 

Future implementation: 

Convene a Process Action Team (PAT) to update doctrine and procedures 

for BH units (CSC/DMHS) to possess and disburse psychotropic medications – To 

improve patient accessibility to psychotropic medications in the combat environment, 

MEDCOM should convene a multidisciplinary PAT to consider authorizing limited 

pharmacy capabilities to DMHS and CSC units during deployment. The panel should 

consist of TOE representatives from psychiatry, nursing, pharmacy, and medical 

leadership. Issues to address should include extent of the formulary, resupply, medical 

reporting, security, and dispensing. The battalion aid station and/or dental units can be 

used as models. 

DISCUSSION

MHAT used the Behavioral Health Survey, Behavioral Health Interview, and 

LRMC Chart Review information to prepare this analysis. There was no comprehensive 

psychotropic medication prescription or utilization tracking system in OIF. 

I. Behavioral Health Surveys and Interviews

Instrument Development: MHAT developed survey and interview instruments 

to test the questions related to the availability of psychotropic medications, laboratory 

services, and kinds of medications used. 

Statements and questions appeared in the Behavioral Health Provider Survey. The 

respondent was directed to circle a number corresponding to the degree to which 

he/she agreed or disagreed with the survey statement. The degree of responses 

ranged from Strongly Disagree to Strongly Agree. Other survey questions asked the 

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respondent to write in an answer. Pertinent survey statements and questions are listed 

below: 

 There has been adequate availability of appropriate psychiatric medications. 

(Circle number) 

 What medications have been needed, but not available? (Write in answer) 

 Laboratory services have been sufficiently available. (Circle number) 

 What labs have been needed but not available? (Write in answer) 

The Behavioral Health Provider Interview posed these questions: 

 What resources do you lack to conduct your mission? How does it impact? 

Survey Method: Units selected for the survey were Division Mental Health 

Sections, Combat Support Hospitals, Combat Stress Control Medical Detachments and 

Companies, and Area Medical Support Battalions. Behavioral Health Officers, Mental 

Health NCOs, Mental Health Specialists, and Occupational Therapy Technicians were 

selected to participate in the survey. Surveys required approximately 45 minutes to 

complete. A non-attribution environment was provided for participants. Surveys were 

collected by MHAT personnel and later entered into a database for analysis. No error 

analysis was conducted to assess mistakes made during data entry. 

Interview Method: Units selected for the survey were Division Mental Health 

Sections, Combat Support Hospitals, Combat Stress Control Medical Detachments and 

Companies, and Area Medical Support Battalions. Behavioral Health Officers, Mental 

Health NCOs, Mental Health Specialists, and Occupational Therapy Technicians were 

selected to participate in the interviews. Interviews were conducted in small groups, 

comprised of 3-5 personnel. Whenever possible, officers and enlisted groups were 

interviewed separately. Interviews were conducted by 1-2 MHAT personnel, and 

required approximately 1 to 11⁄2 hours to complete. A non-attribution environment was 

provided for the interview participants. MHAT personnel took interview notes during the 

session, and later entered these notes into a database for analysis. No error analysis 

was conducted for to assess mistakes made during data entry. 

Analysis of Surveys and Interviews: Analysis of the surveys and interview 

database utilized tools in Microsoft Access. For the purposes of this psychotropic 

medication analysis, only the responses of psychiatrists and psychiatric nurses were 

used. The responses of others were excluded because their unfamiliarity with 

medications and laboratory requirements would likely skew results. Results were 

compared to the raw number of database entries for the purpose of generating a ratio or 

percent value. 

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II. LRMC Chart Review

 

Source of Data: Using both TRAC2ES and LRMC’s homegrown database, 

MHAT identified Army behavioral health evacuees that were transferred from OIF to 

LRMC. All of these behavioral health charts, both inpatient and outpatient, were 

requested by the MHAT for review. MHAT personnel reviewed the charts for 

information considered relevant to Army OIF behavioral health evacuations, and 

entered this information into a Microsoft Access file. For the purposes of this 

psychotropic medication analysis, MHAT identified number of patients evacuated using 

medications, and types of medications prescribed in OIF. The list of data points 

collected in this chart review appears in Annex D. 

Method of Analysis: Analysis of the LRMC Chart Review database utilized 

tools in Microsoft Access and Excel. Sorting results were compared to the total number 

of database entries for the purpose of generating a ratio or percent value. 

RESULTS

Availability of Psychotropic Medications: From 27 Aug – 30 Sep 03, 52% of 

the 25 psychiatrists and psychiatric nurses reported that psychotropic medications were 

not adequately available. Table 1 shows the results by type of behavioral health unit. 

Table 1: Availability of Psychotropic Medications 

Type of Unit 

# of Disagree & 

Strongly Disagree 

Responses 

# Of Respondents 

% Disagree or 

Strongly

Disagree 

Division Mental 

Health Section 2 3 66.7

Combat Stress 

Control Co/Det 8 14 57.1

Combat 

Support 

Hospital

3 6 50.0

Medical 

Brigade 0 2 0.0

Total 13 25 52

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Types of Psychotropic Medications Needed: Of those psychiatrists who 

reported that psychotropic medications were not adequately available, 50% indicated 

the need for a broader range of antidepressant medications to include several SSRIs 

and non-SSRIs. Thirty-three percent indicated that hypnotics/sleeping medications 

(such as Trazodone, Restoril, and Ambien) would be helpful in the formulary. Thirtythree percent reported that stimulants, such as Ritalin, should be available in the 

formulary.

Availability of Laboratory Services: Although less than half of the 25 

psychiatrists and psychiatric nurses reported laboratory services were not adequately 

available to support psychiatric evaluations and treatment, those in hospital settings 

tended to be more dissatisfied with lab support (see Table 2). Providers indicated that 

among the needed laboratory studies were blood alcohol level, urine drug screen, 

thyroid stimulating hormone, and serum levels of mood stabilizers (i.e., Depakote, 

Tegretol, and Lithium). 

Table 2: Availability of Laboratories 

Type of Unit 

# of Disagree & 

Strongly Disagree 

Responses 

# of Respondents 

% Disagree or 

Strongly

Disagree 

Division Mental 

Health Section 1 3 33.3

Combat Stress 

Control Co/Det 6 14 42.9

Combat 

Support 

Hospital

4 6 66.7

Medical 

Brigade 0 0.0

Total 11 25 44.0

2

Early Medication Shortages: Behavioral health units without direct pharmacy 

support (i.e., DMHS and CSC units) anecdotally reported that medications were difficult 

to prescribe during the initial phase of the conflict. Anticipating this shortage, 25% (2) of 

8 behavioral health units deployed with a supply of unregulated psychotropic medication 

to cover expected shortages. 

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APPENDIX 10 (Pastoral Care Assessment) to ANNEX B to OIF MHAT REPORT 

PURPOSE

The OIF MHAT Pastoral Care assessment provides an overview of the Unit Ministry 

Team (UMT) involvement in suicide prevention training and behavioral health care of 

Soldiers deployed to Kuwait and Iraq, to include care of families and Soldiers at Ft. 

Stewart, Georgia during and after deployment of units from that installation.

METHODOLOGY 

All instruments and reports developed and utilized by the MHAT were reviewed to 

discover findings applicable to UMTs, to include the UMT survey and interviews 

conducted with various chaplains in theater and at Ft. Stewart. The UMT survey was 

developed at the beginning of the deployment, to collect data from both chaplains (56A) 

and chaplain assistants (56M) regarding suicide prevention efforts, relationships to 

commanders and mental health providers, and to discern what issues were most 

important to Soldiers and to UMTs. The UMT survey was given to 94 UMT members 

located throughout Kuwait and Iraq.

BACKGROUND

The Office of the Surgeon General’s (OTSG) inclusion of a pastoral care consultant on 

the OIF MHAT is a powerful reinforcement of the relationship of Unit Ministry Teams 

(UMTs) with behavioral health and the importance of pastoral care to the well being of 

Soldiers. Chaplains and Chaplain Assistants have always been key members of the 

commander’s team for identifying Soldiers who have needs, whatever those needs 

might be, and assisting the commander in meeting those needs. UMTs are significant 

providers of mental, behavioral, and emotional health care when they provide Religious

Support to Soldiers and their families. UMTs are one portal for Soldiers to access 

behavioral health care and, vice versa, an important portal for behavioral health 

providers to access Soldiers. 

FINDINGS

From the UMT Survey: 

1. Many UMT personnel are not trained in the Army’s suicide prevention 

program. 

Nearly half (46%) of the UMT personnel have not been trained in the current Army 

suicide intervention techniques -- the Applied Suicide Intervention and Skills Training

(ASIST) or in the Army’s “Menningers” course for UMTs. Significantly more active 

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component UMT personnel have been trained in ASIST/Menningers (74%) than have 

reserve component UMT personnel (34%). 

2. Many UMT members conducted suicide prevention training for their units prior 

to deploying. 

69% of the respondents stated that they had conducted suicide prevention training for 

their units prior to deployment. Of the 31% who did not, 42% stated that they joined the 

unit following deployment, 19% stated that someone else had done the predeployment 

briefings for the unit, and 12% stated that they did not do it predeployment because they 

do it annually or quarterly. Only 15% said that they did not do it because they were too 

busy or didn’t have command support. Most of the training given was given that the 

company (46%) or battalion (34%) level. 

In addition, most (77%) UMT members felt competent in providing a quality unit suicide 

prevention program. Only 4% reported not feeling competent to do so. However, the 

enlisted members and those from the reserve components felt significantly less

competent than their officer or active component counterparts. 

3. Some commanders have not taken ownership of or are not resourcing their 

unit’s suicide prevention program. 

While 56% of the respondents felt the commander was taking ownership and resourcing 

the unit suicide prevention program, 16% felt the commander was clearly not taking 

ownership of the program; 28% of the respondents felt the commander was only 

lukewarm about the unit suicide prevention program. Enlisted UMT members and those 

from the reserve components feel significantly stronger that their commanders are not 

taking ownership and/or resourcing the suicide prevention program compared with their 

officer or active component counterparts. 

4. Many chaplains do not feel their relationship with their local BH providers is 

functional. 

While only 16% report a poor functioning relationship, only 55% feel they have a good 

one. Further, the enlisted UMT members and those from the reserve components 

report a significantly poorer relationship with their local BH provider(s) than their officer 

or active component counterparts. 

5. Uncertain redeployment dates, family separation/problems, and 

command/leadership problems are the three main issues impacting Soldiers. 

Table 1: UMT’s Perception of the Top Five Issues Impacting Soldiers 

Issue Number 

Percent of 

Respondents 

Uncertain Redeployment Dates 53 56% 

Family Separation or Family Problems 42 45% 

Command/Leadership Relations 27 28% 

High OPTEMP / Work Conditions 21 22% 

Communication with Home 19 20% 

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6. Better logistical support, certain redeployment dates, and having units fully

staffed with trained UMT members were the top three things that would best 

impact the UMT mission. 

26% of the respondents identified logistical shortages as the single biggest issue 

impacting their UMT mission. UMT members identified the need for items such as 

computers, printers, internet access, phone access, a vehicle, tentage, and religious 

education/family support materials. 

14% of the respondents identified having a certain redeployment date as most helpful to 

their UMT mission. 13% identified having their units fully staffed with personnel who are 

trained and spiritually committed. One division chaplain noted that he was short 7 

battalion chaplains at the time of the survey. 

7. UMT members identified other chaplains, family, and other Soldiers as their 

primary source of personal support. 

38% of the UMT members reported another chaplain as a source of support, 25% 

identified family as a source of support, and 21% reported other Soldiers as a source of 

support. 13% of the UMTs identified God as a source of personal support. 

From the Soldier Well-Being (SWB) Survey: 

8. Soldiers report high levels of distress and interest in receiving help. 

Sixteen (16%) of OIF Soldiers reported currently experiencing a moderate and 7% 

reported currently experiencing a severe stress, emotional, or family problem. Overall, 

15% of Soldiers reported interest in receiving help. Use of mental health services. Of 

the Soldiers who screened positive for depression, anxiety, or traumatic stress, only 

27% reported receiving help at any time during the deployment from a mental health 

professional, general medical doctor, or chaplain. Of the Soldiers who reported interest 

in receiving help, only 32% received some form of help. 

From the Behavioral Health Survey: 

9. BH personnel generally have good communications with the commanders and 

unit ministry teams (UMT) in their areas of operation. 

65% of the respondents reported good communications with local commanders and 

71% reported good communications with their local UMT. Only 11% and 8% 

(respectively) felt they had particularly poor communications. And, 82% report that 

commanders in their area of operations actively request BH services. 

From the Primary Care Survey: 

10. Primary care personnel generally refer Soldiers with BH issues to a BH 

provider. 

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80% of the respondents refer their patients with BH issues to a BH provider. 20% will 

refer them to a chaplain, and 10% may treat them directly. This varied by rank. 

Enlisted primary care personnel never treated patients with BH issues themselves, 

while 16% of the officers would treat them directly. 

From Behavioral Health Interviews: 

11. Chaplains are viewed as excluding behavioral health providers from the 

‘chaplain’s program.’ 

Slightly less than half of the behavioral health officers indicated suicide prevention 

classes as their most effective intervention. Several indicated they did not do suicide 

prevention because they viewed it as a chaplain program. “We have also been 

instructed not to do suicide prevention programs (because it was the chaplains). Three 

officers from other units indicated they did suicide prevention because the chaplain in 

their AO was not doing suicide prevention or did it poorly. 

RECOMMENDATIONS

1. Ensure UMTs are 100% filled in a combat environment, especially at brigade 

and battalion levels. 

Supervisory UMTs are critical to ensuring that subordinate UMTs are appropriately 

staffed, are accomplishing the mission according to standard, and that commanders are 

aware of the value and need to own and resource religious support. UMTs at all levels 

must be fully staffed – particularly under combat conditions – as this is the chaplaincy’s 

“first mission.” TDA organizations and home stations should be augmented by reserve 

chaplains and/or local clergy where necessary. 

2. Improve Suicide Awareness and Prevention Programs. 

Increase Tempo and scope of ASIST training. Chaplains and Assistants in 

both Active and Reserve Components need to attend ASIST training at the Basic 

level and be able to develop and implement programs in their unit at the 

company level or below. Supervisory chaplains, Family Life Chaplains, and 

Hospital Chaplains (at a minimum) should attend the longer ASIST “training-fortrainers” course in order to be able to conduct training for a variety of both 

military and civilian personnel in units. 

Supervisory Chaplain’s must be involved. Supervisory chaplains must 

monitor the programs of their technical subordinates and ensure that training 

meets the standard. This will probably involve interface with commanders and 

other leaders in the subordinate unit to ensure priority of the training is 

established on training calendars and that resources are provided to conduct 

training, to include place and company level participation. Supervisory chaplains 

should also have direct relationships with their primary care and behavioral 

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health counterparts to ensure the programs have multiple echelons of support in 

both UMT and behavioral health chains of responsibility. 

Integrate with Behavioral and Primary Care Providers. Programs conducted 

at the battalion/company level, though coordinated and executed by the trained 

unit UMT, should include participation by behavioral care and primary care 

providers. At a minimum, points of contact should be established, published, and 

given to Soldiers and family members at the time of training. Ideally, actual 

personnel from behavioral health (either providers or enlisted BH specialists) 

should be present at such training and participate at appropriate levels. 

3. Execute an aggressive UMT pastoral care outreach program. 

A high percentage of Soldiers reported interest in receiving mental health support 

and/or screened positive for a mental health problem. However, data suggest 

that significant barriers are preventing Soldiers from receiving help, such as 

transportation constraints, knowing where to get help, mental health services not 

being perceived as available, and stigma. The data also indicated that chaplains 

were accessed at relatively low rates. Establishing a predictable, regular, and

visible presence at the company/battalion level is essential. 

UMTs can reduce and/or eliminate many of these barriers by physically going to 

Soldiers who need and/or want help. The UMT doctrine of ‘Ministry of Presence’ 

works when UMTs go out and live and work among Soldiers at the lowest levels. 

UMTs report that their outreach efforts are hindered by the limited logistical 

support they receive from commanders and leaders. UMTs must work with 

commanders and leaders to solve the transportation and communication issues 

they face in order to get UMTs out where Soldiers live and work. The 

supervisory chaplain is a critical link in keeping UMTs aware of appropriate and 

effective doctrinal ways of doing business and in communicating to commanders 

and leaders the importance of properly resourcing UMTs for mission 

performance. 

4. Educate primary players in the Role of UMT involvement in Combat and 

Operational Stress Control. 

Commanders and Leaders must embrace and own the complete Religious 

Support Program. Religious Support is a Commander’s program. Officer Basic 

and Advance Courses, as well as NCO Basic and Advance Courses, need to 

emphasize the role of the UMT in providing for Soldier spiritual health, which is a 

significant component of behavioral and mental health. Leaders need to 

understand that their ownership of and logistical support for the Suicide 

Awareness & Prevention Programs and other UMT initiatives is essential to the 

effectiveness of those programs. Supervisory chaplains are a critical link in 

getting this message to commanders both directly and indirectly through the 

higher chain of command. 

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Medical Personnel, both primary care and behavioral health providers, 

must understand the role of UMTs in support of total Soldier well being. 

AMEDDC&S needs to utilize their own Department of Pastoral Ministry Training

to educate officers and NCOs about the role of UMTs and the mutual benefits

both staff and patients of inter-disciplinary peer relationships. MEDCOM Medical 

Centers and Army Community Hospitals need to use chaplains in in-service 

training for medical personnel. FORSCOM Combat Support Hospitals need to 

ensure UMTs are a regular part of hospital patient care and treatment programs 

and include Pastoral Care as a training topic for personnel. 

Chaplains need to understand their own role in COSC. FM 1-05 (Religious

Support) has an Appendix B (FM 8-51, COSC in Theater of Operations, has the 

same appendix), which details COSC issues that UMTs should be aware of and 

ready to identify. That appendix needs more attention in training at both 

institution and garrison. The Chaplain Center and School should review how 

officer and NCO courses assist UMTs to work with COSC issues, make 

assessments and referrals to Behavioral Health personnel, and in general the 

role of the UMT in working with all medical personnel to provide easy access to 

care for Soldiers who have needs. Garrison and supervisory chaplains need to 

include a review of FM 1-05, Appendix B, with perhaps the assistance of local 

CSC providers, to sustain and improve skills. 

MEDCOM UMTs and FORSCOM UMTS assigned to FORSCOM medical units 

should also attend the new COSC course that the MHAT is proposing for the 

AMEDDC&S (based on the current 2wk long OT COSC course). Other UMTS 

may consider attending the course as well and it should be included in the list of 

courses that DPMT offers to the Army chaplaincy. 

5. Develop and field a spiritual health needs assessment and unit climate tool for 

the operational environment. 

In order to accurately and systemically determine the spiritual needs of deployed 

Soldiers and ensure those needs are being met, a standardized “spiritual needs 

assessment” should be developed. Such an instrument must be easy to use, be 

compatible with the similarly developed behavioral health needs assessment, 

and contain some spiritual-unique elements. A Soldier/unit climate tool would 

also be helpful in order for UMTs to be able to keep a finger on the pulse of the 

unit climate in a more defined manner than traditionally done. Such tools 

supplement, but cannot replace, “ministry of presence” and the “personal delivery 

of religious support.” 

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APPENDIX 11 (References) to ANNEX B to OIF MHAT REPORT 

Bacon BL, Staudenmeier JJ: A historical overview of combat stress control units of the 

US Army. Mil Med 168, 9:689-693, 2003. 

Bourne, PG, Rose RM, Mason JW: 17-OHCS levels in combat: Special Forces “A” 

team under threat of attack. Arch Gen Psychiatry, 19:135-140, 1968. 

DOD Directive 6490.2, Joint Medical Surveillance, 30 August 1997. 

DOD Directive 6490.5, Combat Stress Control (CSC) Programs, 23 February 1999. 

DOD Instruction 6490.3, Implementation and Application of Joint Medical Surveillance 

for Deployment, 7 August 1997. 

Field Manual 3-0, Operations, 14 June 2001.

Field Manual 6-0, Mission command: Command and control of Army forces, 11 August 

2003. 

Field Manual 8-55, Planning for health service support, 9 September 1994. 

Field Manual 8-51, Combat stress control in a theater of operations: Tactics, 

techniques, and procedures, 20 Jan 1998. 

Jones FD: Psychiatric principles of future warfare. In War Psychiatry, pg. 113-132. 

Edited by Jones FD, Sparacino LR, Wilcox, VL, Rothberg JM, Stokes JW, Borden 

Institute, OTSG, 1995. 

Lincoln AE, Smith GS, Baker SP: The use of existing military administrative and health 

databases for injury surveillance and research. Am J Prev Med 18(3S): 8-13, 2000. 

Martin JA, Fagan JG: Army mental health units in the theater of operations: An 

overview of the gulf war. In: The Gulf War and Mental Health: A comprehensive guide, 

pg. 19-32. Edited by Martin JA, Linette SR, Belenky G, Westport CT. Praeger 

Publishers, 1996. 

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